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IHUMAN CASE # 4: GI Evita Alfonso - 48-year-old female CC: progressive, intermittent right upper quadrant pain

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IHUMAN Case # 4 Perpetual Anita Aseme IHUMAN CASE # 4: GI Evita Alfonso NURS5342 Advanced Health Assessment LaMicha Hogan, APRN, MSN FNP-BC Molly Toon, DNP, APRN, CPNP-PC Date Mar... ch 21, 2021 IHUMAN CASE # 4: GI Evita Alfonso - 48-year-old female CC: progressive, intermittent right upper quadrant pain Case: Evita Alfonso Date: March 21, 2021 CC: 48 y/o F Chief complaint is a short 1-2 statement or word phrase from patient and should be listed in “quotes” “My stomach has been hurting really bad over the past 2 seeks” HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts 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 which has increased in severity in the past 2 days. The pain radiates to the right 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 illness/hospitalizations/immunizations Negative for any chronic illnesses. She has occasional heartburn and arthritis Frequent episodes of common colds and as child No hospitalizations, trauma or other injuries SurgHx type/when/why/complications Tubal ligation [Show More]

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