Virginia Lee A 54-Year-Old Female With Chronic Abdominal Pa

VIRGINIA LEE - A 54-YEAR-OLD FEMALE WITH CHRONIC ABDOMINAL PAIN: A MASTERCLASS IN NURSING CLINICAL JUDGMENT, HOLISTIC ASSESSMENT, EVIDENCE-BASED DIAGNOSIS, AND PATIENT-CENTERED MANAGEMENTI. Patient Identification Name: Virginia Lee Age: 54 years Gender: Female Ethnicity: African American Marital Status: Married Occupation: Administrative assistant Setting: Outpatient primary care clinic with laboratory and imaging access Source of History: Patient (reliable historian) II. Chief Complaint (CC) Ive been having stomach pain on and off for months. III. History of Present Illness (HPI) Virginia Lee is a 54-year-old female presenting with chronic, intermittent abdominal pain for 6 months. OLDCART Analysis Component Findings Onset Gradual Location Epigastric and right upper quadrant (RUQ) Duration 6 months Character Dull, aching pain; occasionally sharp after meals Aggravating Factors Fatty foods Relieving Factors Rest, antacids (partial relief) Radiation Sometimes to right shoulder bladeComponent Findings Timing 30-60 minutes after meals Severity 6/10 at worst Associated Symptoms Nausea (intermittent) Bloating Early satiety Occasional heartburn No vomiting No hematemesis No melena No hematochezia No unintentional weight loss No fever IV. Past Medical History Hypertension (10 years) Hyperlipidemia GERD Obesity (BMI 31) V. Surgical History Cesarean section (age 29)VI. Medications Lisinopril 10 mg daily Atorvastatin 20 mg nightly Omeprazole 20 mg daily Occasional NSAIDs