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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 EV5 5 5 5
ITA ALONSO
5
(48 YRS OLD,ABDOMINAL PAI
5 5 5
N)
,CC:5485y/o5F HPI:5pertinent5s/s;5+/-5ROS/prior5episodes/recent5travel/ill5contacts
Chief5complaint5is5a5short51-
25statement5or5word5phrase5from5patient5and5should5be5 Mrs.5Alonso5is5a548-year-
listed5in5“quotes” old5female5patient5who5presented5to5the5clinic5with5a5progressive,5intermittent5ri
ght5upper5quadrant5pain5for5the5past525weeks5and5which5has5increased5in5severity
“My5stomach5has5been5hurting5really5bad5over5 5in5the5past525days.5The5pain5radiates5to5the5right5shoulder.5She5also5complains5of
the5past525seeks” 5associated5symptoms5like5nausea,5vomiting,5anorexia5since5the5past525days.5She5
has5had5previous5recurrent5self-
resolving5symptoms5over5the5last5one5year.5Pain5used5to5be5precipitated5by5fast5fo
od5but5not5occurs5with5all5foods5and5unresponsive5with5antacids5and5NSAIDS.
Onset:525weeks5ago,5with5symptoms5becoming5more5dreadful525days5ago5Locatio
n:5Right5upper5quadrant5and5occasionally5radiated5to5the5right5shoulder5Duration:5
Pain5has5been5constant5since5it5started5this5time;5in5the5past5it5only5lasted51-25days.
Character:5 Crampy5gnawy5achiness
Aggravating/alleviating5factors:5Pain5gets5worse5with5meals5and5unresolved5wit
h5antacids5and5NSAIDs
Related5symptoms:5Nausea.5Vomiting,5anorexia5with5onset5of5symptoms525days5a
go.5Denies5any5recent5exposure5to5other5ill5contacts.5She5has5had5similar5symptom
s5previously
Treatments:5Has5tried5OTC5antacids5and5ibuprofen5without5relief
Significance:5 Pain5starts5with5a5scale5of52-35and5gets5up5to56-
7.5She5reports5pain5has5kept5her5home5from5work.
PMHx5child/adult5illness/hospitalizations/immunizatio SurgHx5type/when/why/complications
ns
Negative5for5any5chronic5illnesses.5She5has5occasi Tubal5ligation
onal5heartburn5and5arthritis
Frequent5episodes5of5common5colds5and5as5child5
No5hospitalizations,5trauma5or5other5injuries
, Immunizations:5States5her5immunizations5are5c
urrent.5She5had5the5influenza5vaccine5this5seaso
n5and5still5got5the5flu.
FamHx SHx
Grandparents5(if5known)/Parents/siblings/children Tobacco/vaping/ETOH/illicit5 drug5 use/occupational/environmental/relationships
Grandparents- She5reports5that5she5drinks5a5glass5of5wine5with5dinner5most5nights;5She5denies5an
5states5no5known5history5Father5is5705years-
y5tobacco5or5recreational5drug5use
old5and5still5alive5and5well5(70):5heart5diseas
e,5peptic5ulcer5disease
Mother5is5695years-
old5and5alive:5breast5cancer5in5remission;5chole
cystectomy5for5cholelithiasis
Reproductive5Hx Allergies5(Food,5Drug,5Environmental,5etc)
Female:Age5of5menarche/menstruation5cycle5duration/gra
vida5para5status/Childbirth5hx/sexual5hx5and5concerns/LM No5known5drug5allergies
P/menopause
Breast/cervical5 screening5 (if5any)
Male:5Sexual5hx5and5concerns/issues5with5fertility5(i
f5any)/Testicular5or5prostate5screening5(if5applicabl List5of5Medications/supplements5(prescription,5OTC,5complementary
e)5Screening5for5STI’s5(if5applicable) 5alternative5therapies)
Pertinent5sexual5history:5Not5sexually5active5and5d Antacids5as5needed5for5"heartburn"
enies5any5sexual5concerns Ibuprofen54005mg5three5times5daily5as5needed5for5knee5pain5Multivitam
ins
Review5of5Systems:5(ROS)5Use5this5column5to5d From5the5ROS:5list/highlight5the5current5symptoms/complaints5to5generate5a5l
ocument5the5ROS5below. ist5of5“reported5or5denied”5symptoms5below:
General:5Reports5some5weight5loss,5fever,5night5s
Pertinent5positive5ROS:5Reports5some5weight5loss,5fever,5night5sweats,5and5diffi
weats,5and5difficulty5sleeping
culty5sleeping;5RUQ5abdominal5that5worsens5with5food5and5pain5scale5of52-
HEENT:5Denies5headaches,5changes5in5vision,
53/105and5progresses5to56-7/10,56/10.5Anorexia,5nausea5and5vomiting5at5onset.
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