Ariela Hernandez
Acute onset
dyspnea and
syncope iHuman
case study (4
Different
Versions)LATEST
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MARCH 2023
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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
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.
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).
History Questions
Ariela Hernandez is an Acute onset dyspnea and syncope iHuman case study essay The
history questions to ask Ariela Hernandez are:
1. Where do you live?
2. Do you have any children, spouse, or partner?
3. Do you smoke?
4. How many years have you been smoking?
5. How much do you smoke a day?
6. Do you have any history of lung disease?
7. Do you have asthma?
8. Do you use any recreational drugs?
9. Tell me about any current or past medical problems.
10.Are you taking any prescription medications?
11.Are you taking any over the counter or herbal medications?
12.Do you drink alcohol? If so, what do you drink and how many drinks per day?
13.Do you take insulin for diabetes?
14.Do you drink caffeinated beverages or eat chocolate?
15.Tell me about your diet, what you normally eat?
16.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?
17.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?
18.Are you coughing up any sputum?
19.Is there any pattern to your cough?
20.What treatments have you had for your cough?
21.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?
22.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?
23.Have you ever been hospitalized [Show Less]