NRNP 6531 Week 7 Assignment; iHuman Gastrointestinal Case (Full SOAP)
Course : Walden
Contributed : Kate
- $20.00
iHuman Gastrointestinal Case
CC: RUQ abdominal pain HPI:
- year-old Hispanic female. A&O x 4. Appears well developed, well nourished. Patient reports having intermittent upper right quadrant abdominal pain that started 2 weeks ago. Has progressively gotten worse over the last 2 days and is now constant. Describes it as a constant deep abdominal cramping, gnawing, and achiness under right ribs deep inside which radiates with pain in the right shoulder. Severity 4/10. Reports nausea and vomiting and fever for 2 days. Reports history of acid reflux. Use of antacids and Ibuprofen provides no relief for her current abdominal pain. Patient reports pain is brought on by eating food. Patient reports not drinking adequate amount of fluid because of the vomiting. History of abdominal pain a few times over the last year that has always gone away on its own, but never this severe. Patient denies dysphagia, chest pain, SOB, blood in emesis, blood in stool or blood in urine. Denies any one event or activity associated with the onset of her abdominal pain.
Location: Abdomen Onset: 2 weeks ago
Character: constant cramping, gnawing, achiness in upper right abdomen under ribs Associated signs and symptoms: nausea, vomiting, fever, radiating pain to right shoulder. Timing: After eating meals
Exacerbating/relieving factors: Eating food makes it worse. No relieving factors, antacids do not work.
Severity: 4/10 today. Starts as a 2-3/10 and increases up to 6-7/10 on other days. Allergies: NKDA
Medications:
- Ibuprofen 400mg TID prn pain
- OTC antacids prn acid reflux
PMH:
- Occasional acid reflux, heartburn, relieved with OTC antacids
- Occasional knee pain and stiffness, with frequent use of Ibuprofen prn
Hospitalizations: No open surgeries. Childbirth. G3P3. Bilateral tubal ligation with last delivery. Preventative Health:........ Continue
