Ariela Hernandez Acute Onset Dyspnea and Syncope iHuman Case Study

Ariela Hernandez Acute Onset Dyspnea and Syncope iHuman Case Study

Ariela Hernandez Acute Onset Dyspnea and Syncope iHuman Case Study

64 years
5? 3?
200 pounds

 

Ariela Hernandez

Chief complaint:

Acute onset dyspnea and near syncope

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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.

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.

o   Document abnormal findings in your problem list.

o   There is no penalty for doing more than what is required. This is worth 40% of your overall case play score.

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.

o   Document abnormal findings in your problem list.

o   There is no penalty for doing more than what is required. This is worth 40% of your overall case play score.

3. Complete the PROBLEM LIST exercise, pick those problems that match what you have on your problem list.

o   This is worth 20% of your overall case play score.

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

tell 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

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

 

Ariela Hernandez Acute Onset Dyspnea and Syncope iHuman Case Study

Reviewed FSG home glucose monitoring results. Still running a bit high. Encouraged patient to schedule visit with PCP.

S: Mrs. Hernandez is a 64-year-old woman who is here for routine follow-up 2 weeks s/p right knee replacement. Ariela Hernandez Acute onset dyspnea and syncope iHuman case study essay. Her only complaint is physical therapy is harder than she expected and she still has residual pain. She continues to smoke against our recommendations.

 

O: VS normal. Surgical scar healing well without signs of infection. Lungs clear, Heart RRR w/o murmur, Abd soft and non-tender, Neuro reflexes x 2 throughout, MSK right knee healing well.

 

A: Normal recovery for right-knee replacement in obese type 2 diabetic patient who continues to smoke.

 

P: Continue physical therapy, f/u PCP for diabetes management, continue to encourage weight loss and stress need for ambulation Q2 hours throughout waking hours. Continue to stress the importance of smoking cessation.