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
Case: Evita Alfonso
Date: March 21, 2021
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.
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