i-Human Case Study Evita Alfonso, 48yrs Old Female CC:
Progressive Abdominal Pain “Mrs. Alfonso is a 48-year-old female
patient who presented to the clinic with a progressive….” EXPERT
FEEDBACK SOLUTIONS
[
, Case: Evita Alfonso
CC: 48 y/o F HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts
Chief complaint is a short 1-2 statement or word phrase
from patient and should be listed in “quotes” Mrs. Alfonso is a 48-year-old female patient who presented to the clinic with a
progressive, intermittent right upper quadrant pain for the past 2 weeks and
“My stomach has been hurting really bad over which has increased in severity in the past 2 days. The pain radiates to the right
the past 2 seeks” shoulder. She also complains of associated symptoms like nausea, vomiting,
anorexia since the past 2 days. She has had previous recurrent self-resolving
symptoms over the last one year. Pain used to be precipitated by fast food but not
occurs with all foods and unresponsive with antacids and NSAIDS.
Onset: 2 weeks ago, with symptoms becoming more dreadful 2 days ago
Location: Right upper quadrant and occasionally radiated to the right shoulder
Duration: Pain has been constant since it started this time; in the past it only
lasted 1-2 days.
Character: Crampy gnawy achiness
Aggravating/alleviating factors: Pain gets worse with meals and unresolved
with antacids and NSAIDs
Related symptoms: Nausea. Vomiting, anorexia with onset of symptoms 2 days
ago. Denies any recent exposure to other ill contacts. She has had similar
symptoms previously
Treatments: Has tried OTC antacids and ibuprofen without relief
Significance: Pain starts with a scale of 2-3 and gets up to 6-7. She reports pain
has kept her home from work.
PMHx child/adult SurgHx type/when/why/complications
illness/hospitalizations/immunizations
Negative for any chronic illnesses. She has Tubal ligation
occasional heartburn and arthritis
Frequent episodes of common colds and as child
No hospitalizations, trauma or other injuries
Progressive Abdominal Pain “Mrs. Alfonso is a 48-year-old female
patient who presented to the clinic with a progressive….” EXPERT
FEEDBACK SOLUTIONS
[
, Case: Evita Alfonso
CC: 48 y/o F HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts
Chief complaint is a short 1-2 statement or word phrase
from patient and should be listed in “quotes” Mrs. Alfonso is a 48-year-old female patient who presented to the clinic with a
progressive, intermittent right upper quadrant pain for the past 2 weeks and
“My stomach has been hurting really bad over which has increased in severity in the past 2 days. The pain radiates to the right
the past 2 seeks” shoulder. She also complains of associated symptoms like nausea, vomiting,
anorexia since the past 2 days. She has had previous recurrent self-resolving
symptoms over the last one year. Pain used to be precipitated by fast food but not
occurs with all foods and unresponsive with antacids and NSAIDS.
Onset: 2 weeks ago, with symptoms becoming more dreadful 2 days ago
Location: Right upper quadrant and occasionally radiated to the right shoulder
Duration: Pain has been constant since it started this time; in the past it only
lasted 1-2 days.
Character: Crampy gnawy achiness
Aggravating/alleviating factors: Pain gets worse with meals and unresolved
with antacids and NSAIDs
Related symptoms: Nausea. Vomiting, anorexia with onset of symptoms 2 days
ago. Denies any recent exposure to other ill contacts. She has had similar
symptoms previously
Treatments: Has tried OTC antacids and ibuprofen without relief
Significance: Pain starts with a scale of 2-3 and gets up to 6-7. She reports pain
has kept her home from work.
PMHx child/adult SurgHx type/when/why/complications
illness/hospitalizations/immunizations
Negative for any chronic illnesses. She has Tubal ligation
occasional heartburn and arthritis
Frequent episodes of common colds and as child
No hospitalizations, trauma or other injuries
