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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