Ariela Hernandez Acute Onset Dyspnea and Syncope iHuman Case Study Essay

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Ariela Hernandez Acute onset dyspnea and syncope iHuman case study essay

64 years
5′ 3″
200 pounds

Ariela Hernandez

Chief complaint:
Acute onset dyspnea and near syncope

Mrs. Hernandez is a 64 year old obese female with HTN, current smoker for the past 40 years, diabetes, right knee replacement surgery 6 weeks ago, complaints of acute onset dyspnea and near syncope started approximately 3 hours ago.  Associated symptoms SOB, cough, right calf slightly tender and swollen.  Physical examination demonstrates signs of possible PE.

Trace to 1+ edema to ankles on left, 2+ edema to knee on right, well healing incisional scar overlying right knee from recent surgery slightly swollen compared to left right calf slightly tender, left calf non tender, no left joint swelling or erythema, no clubbing or cyanosis, extremities are well perfused Ariela Hernandez Acute onset dyspnea and syncope iHuman case study essay.

Abdomen- normal, no tenderness, no masses appreciated, liver of normal size, smooth edge palpable, spleen normal

At the start of the case click on “Show Patient Record, above the Problem List Icon. Note the three tabs: 1) current visit (blank EMR), 2) Pt. Info Forms (contains Vital Signs for current visit) and 3) 1 month ago (contains records from outpatient surgical visit 1 month ago). These tabs provide vital information.  

You must receive an overall score greater than or equal to 80% to have mastered this course.

For this case there are 22 required history questions: (CC (2), HPI/Symptom+ Assoc. Symptoms (10), PMH/Surg/Hosp/Meds/Environment (4), Allergies (1), FH (0), SH (0), Prevention/Risk Behaviors (0), ROS (5). 1. Take the patient’s HISTORY.

• Decide of this is a patient that can be treated as an outpatient; focused case – fewer history questions needed versus a patient who might be hospitalized for treatment (comprehensive case) where all components of a history.

> Document abnormal findings in your problem list. 2. Proceed to perform a PHYSICAL ASSESSMENT.

• Assess vital signs and perform the examination appropriate for the type of case identified by the above history. Ariela Hernandez Acute onset dyspnea and syncope iHuman case study essay. Remember the comprehensive cases require a comprehensive physical.

>  Document abnormal findings in your problem list. 3. Complete the PROBLEM LISTexercise, pick those problems that match what you have on your problem list. 4. Write a concise problem statement.

• Start with a demographic description of your patient and the chief complaint and MSAP. Try to keep your problem statement below 100 words.

  Asked questions:

• What is your name
• How old are you
• Where are you
• Where do you live
• Where and with whom are you living
• Do you have any children, spouse, Significant partner
• Do you practice any religion
• Why are you seeking help today
• Any other symptoms
• How many years have you been smoking
• How much do you smoke a day
• Do you have any history of lung disease
• Do you have asthma
• Do you use any recreational drugs
• How is your overall health
• Telll me about any current or past medical problems
• Are your immunizations up to date
• Are you taking any prescription medications
• Are you taking any over the counter or herbal medications
• Ariela Hernandez Acute onset dyspnea and syncope iHuman case study essay
• Do you drink alcohol? If so, what do you drink and how many drinks per day
• Do you take insulin for diabetes
• Has anyone suggested that you should reduce the amount of alcohol you drink
• Do you drink caffeinated beverages or eat chocolate
• Tell me about your diet, what you normally eat
• Do you have any problems with: nervousness, depression, lack of interest, sadness, memory loss, or mood changes, or ever hear voices that you know are not there
• When you urinate, have you noticed: pain, difficulty starting or stopping, dribbling, incontinence, urgency during day or night. Any changes in frequency? Any blood in your urine
• Are you coughing up any sputum
• Is there any pattern to your cough
• What treatments have you had for your cough
• Do you have problems with: nausea, vomiting, constipation, diarrhea, coffee grounds in your vomit, dark tarry stool, bright red blood in your bowel movements, early satiety, bloating
• Do you have problems with: muscle or joint pain, redness, swelling, muscle cramps, joint stiffness, joint swelling or redness, back pain, neck or shoulder pain, hip pain
• Have you ever been hospitalized
• Tell me about your work
• Do you have any allergies
• Do you have any problems with: headaches that don’t go away with aspirin or Tylenol (acetaminophen), double or blurred vision, difficulty with night vision, problems hearing, ear pain, sinus problems, chronic sore throats, difficulty swallowing
• Have you noticed: any bruising, bleeding gums or other sites of increased bleeding
• Do you have any of the following: heat or cold intolerance, increased thirst, sweating, frequent urination, change in appetite Ariela Hernandez Acute onset dyspnea and syncope iHuman case study essay
• Do you have any of the following: dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, tremor
• Is there a pattern to when you have difficulty breathing
• Do you have any pain in your chest
• Does your chest feel tight or heavy

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• Do you have any of the following problems: fatigue, difficulty sleeping, unintentional weight loss or gain, fevers, night sweats
• Do you have any problems with: itchy scalp, skin changes, moles, thinning hair, brittle nails
• Have you been in a situation where you were sitting or lying still for a long time?
• Are you short of breath when lying down
• Do you awaken at night short of breath?
• Do you have unusual heartbeats (palpitations
• Do you sleep with pillows to help you breathe
• Do you feel as if you are smothering or suffocating?
• Do you wheeze?
• Any previous medical surgical, or dental procedures
• Ever had this illness before
• Do you have pain anywhere, if so where
• What is the most distressing symptom for you
• Has your level of activity recently changed
• Are you in good spirits most of the time
• Does anything make your difficulty breathing better or worse
• Does anything make your cough better or worse
• Do you have a problem with fatigue