IHUMAN CASE # 4: GI Evita Alfonso - 48-year-old female CC: progressive, intermittent right upper quadrant pain Perpetual Anita Aseme IHUMAN CASE # 4: GI Evita Alfons... o NURS5342 Advanced Health Assessment LaMicha Hogan, APRN, MSN FNP-BC Molly Toon, DNP, APRN, CPNP-PC 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 Immunizations: States her immunizations are current. She had the influenza vaccine this season and still got the flu. FamHx Grandparents (if known)/Parents/siblings/children Grandparents- states no known history Father is 70 years-old and still alive and well (70): heart disease, peptic ulcer disease Mother is 69 years-old and alive: breast cancer in remission; cholecystectomy for cholelithiasis SHx Tobacco/vaping/ETOH/illicit drug use/occupational/environmental/relationships She reports that she drinks a glass of wine with dinner most nights; She denies any tobacco or recreational drug use Reproductive Hx Female:Age of menarche/menstruation cycle duration/gravida para status/Childbirth hx/sexual hx and concerns/LMP/menopause Breast/cervical screening (if any) Male: Sexual hx and concerns/issues with fertility (if any)/Testicular or prostate screening (if applicable) Screening for STI’s (if applicable) Pertinent sexual history: Not sexually active and denies any sexual concerns Allergies (Food, Drug, Environmental, etc) No known drug allergies List of Medications/supplements (prescription, OTC, complementary alternative therapies) Antacids as needed for "heartburn" Ibuprofen 400 mg three times daily as needed for knee pain Multivitamins Review of Systems: (ROS) Use this column to document the ROS below. General: Reports some weight loss, fever, night sweats, and difficulty sleeping HEENT: Denies headaches, changes in vision, From the ROS: list/highlight the current symptoms/complaints to generate a list of “reported or denied” symptoms below: Pertinent positive ROS: Reports some weight loss, fever, night sweats, and difficulty sleeping; RUQ abdominal that worsens with food and pain scale of 2- 3/10 and progresses to 6-7/10, 6/10. Anorexia, nausea and vomiting at onset. hearing, pain in ears o sinuses, denies nasal drainage, denies sore throat or difficulty swallowing. Neck/Thyroid: Denies any pain or swelling. Pulmonary: Denies SOB, cough, wheezing, or pain on deep breathing CV: Denies chest pain, palpitations, edema, or syncopal episodes. GI: Report’s nausea vomiting and anorexia. Denies diarrhea or constipations. RUQ abdominal pain. GU: Denies dysuria or difficulty urinating. MS: Denies muscle or joint pain or swelling Heme: No complaints of bruising or frequent epistaxis Lymph: No complaint of cervical lymphadenopathy. Endocrine: No complaint polyuria, polydipsia, polyphagia, or heat/cold intolerance. Derm: Denies unusual moles, rashes, lesions. Neuro: Denies dizziness, seizures or headaches Psych: No complaints of sadness, hopelessness, or panic attacks. Pertinent negative ROS: no recent illness, denies headaches denies constipation and diarrhea, no painful urination, no myalgias or recent trauma; Negative for hip joint deformities or pain. [Show More]
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