NURS5342 IHUMAN CASE # 4: GI Evita Alfonso

NURS5342 IHUMAN CASE # 4: GI Evita Alfonso

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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

March 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

 

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