Exam (elaborations)
IHP IHUMAN CASE STUDY EVITA ALONSO (48 YRS OLD,ABDOMINAL PAIN)
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IHP IHUMAN CASE STUDY EVITA ALONSO (48 YRS OLD,ABDOMINAL PAIN)IHP IHUMAN CASE STUDY EVITA ALONSO (48 YRS OLD,ABDOMINAL PAIN)
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IHP IHUMAN CASE STUDY EV6 6 6 6
ITA ALONSO
6
(48 YRS OLD,ABDOMINAL PAI
6 6 6
N)
,CC:6486y/o6F HPI:6pertinent6s/s;6+/-6ROS/prior6episodes/recent6travel/ill6contacts
Chief6complaint6is6a6short61-
26statement6or6word6phrase6from6patient6and6should6be6 Mrs.6Alonso6is6a648-year-
listed6in6“quotes” old6female6patient6who6presented6to6the6clinic6with6a6progressive,6intermittent6ri
ght6upper6quadrant6pain6for6the6past626weeks6and6which6has6increased6in6severity
“My6stomach6has6been6hurting6really6bad6over6 6in6the6past626days.6The6pain6radiates6to6the6right6shoulder.6She6also6complains6of
the6past626seeks” 6associated6symptoms6like6nausea,6vomiting,6anorexia6since6the6past626days.6She6
has6had6previous6recurrent6self-
resolving6symptoms6over6the6last6one6year.6Pain6used6to6be6precipitated6by6fast6fo
od6but6not6occurs6with6all6foods6and6unresponsive6with6antacids6and6NSAIDS.
Onset:626weeks6ago,6with6symptoms6becoming6more6dreadful626days6ago6Locatio
n:6Right6upper6quadrant6and6occasionally6radiated6to6the6right6shoulder6Duration:6
Pain6has6been6constant6since6it6started6this6time;6in6the6past6it6only6lasted61-26days.
Character:6 Crampy6gnawy6achiness
Aggravating/alleviating6factors:6Pain6gets6worse6with6meals6and6unresolved6wit
h6antacids6and6NSAIDs
Related6symptoms:6Nausea.6Vomiting,6anorexia6with6onset6of6symptoms626days6a
go.6Denies6any6recent6exposure6to6other6ill6contacts.6She6has6had6similar6symptom
s6previously
Treatments:6Has6tried6OTC6antacids6and6ibuprofen6without6relief
Significance:6 Pain6starts6with6a6scale6of62-36and6gets6up6to66-
7.6She6reports6pain6has6kept6her6home6from6work.
PMHx6child/adult6illness/hospitalizations/immunizatio SurgHx6type/when/why/complications
ns
Negative6for6any6chronic6illnesses.6She6has6occasi Tubal6ligation
onal6heartburn6and6arthritis
Frequent6episodes6of6common6colds6and6as6child6
No6hospitalizations,6trauma6or6other6injuries
, Immunizations:6States6her6immunizations6are6c
urrent.6She6had6the6influenza6vaccine6this6seaso
n6and6still6got6the6flu.
FamHx SHx
Grandparents6(if6known)/Parents/siblings/children Tobacco/vaping/ETOH/illicit6 drug6 use/occupational/environmental/relationships
Grandparents- She6reports6that6she6drinks6a6glass6of6wine6with6dinner6most6nights;6She6denies6an
6states6no6known6history6Father6is6706years-
y6tobacco6or6recreational6drug6use
old6and6still6alive6and6well6(70):6heart6diseas
e,6peptic6ulcer6disease
Mother6is6696years-
old6and6alive:6breast6cancer6in6remission;6chole
cystectomy6for6cholelithiasis
Reproductive6Hx Allergies6(Food,6Drug,6Environmental,6etc)
Female:Age6of6menarche/menstruation6cycle6duration/gra
vida6para6status/Childbirth6hx/sexual6hx6and6concerns/LM No6known6drug6allergies
P/menopause
Breast/cervical6 screening6 (if6any)
Male:6Sexual6hx6and6concerns/issues6with6fertility6(i
f6any)/Testicular6or6prostate6screening6(if6applicabl List6of6Medications/supplements6(prescription,6OTC,6complementary
e)6Screening6for6STI’s6(if6applicable) 6alternative6therapies)
Pertinent6sexual6history:6Not6sexually6active6and6d Antacids6as6needed6for6"heartburn"
enies6any6sexual6concerns Ibuprofen64006mg6three6times6daily6as6needed6for6knee6pain6Multivitam
ins
Review6of6Systems:6(ROS)6Use6this6column6to6d From6the6ROS:6list/highlight6the6current6symptoms/complaints6to6generate6a6l
ocument6the6ROS6below. ist6of6“reported6or6denied”6symptoms6below:
General:6Reports6some6weight6loss,6fever,6night6s
Pertinent6positive6ROS:6Reports6some6weight6loss,6fever,6night6sweats,6and6diffi
weats,6and6difficulty6sleeping
culty6sleeping;6RUQ6abdominal6that6worsens6with6food6and6pain6scale6of62-
HEENT:6Denies6headaches,6changes6in6vision,
63/106and6progresses6to66-7/10,66/10.6Anorexia,6nausea6and6vomiting6at6onset.
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