ARIELA HERNANDEZ IHUMAN CASE
STUDY NEW SOLUTION 2023/2024
CASE: ACUTE ONSET OF DYSPNEA AND NEAR SYNCOPE
Comprehensive Hx Overview
Nurse
... [Show More] Information
• Patient name: Ariela Hernandez
• Age: 64
• Reason for visit: C/C Acute onset of dyspnea and near syncope • Height and Weight; sometimes
BMI: 5’3”, 200lbs
• Blood pressure:
• Pulse:
• Temp:
Breathless, clipped , Diaphoretic, cough (smoker) normal per pt, lightheaded
Wine 4-5 glasses per week
Cold 1 month ago
SHx: right knee replacement 6 weeks ago, motrin for pain
Hx: 3-4 bilateral knee pain for years decreased activity helps, 2 packs per day since age 24
FHx: mom DM, HTN, stroke age 80. dad heart attack 50, heart failure, no children, mexico born came at
age 24
Hx HTN for years (lisinopril 10mg, HTZ 25mg, menopause x years, DM,metformin XR750mg x2), knee
arthritis
Worsing Cough this am, Chronic cough (smoker) normal x5 years
Diaphoretic, lightheaded this am, upon standing
SOB x 3 hours while washing dishes, + with activity
- 5 lbs since surgery, right knee pain after surgery, increase swelling to right leg after surgery Obesity
s/p knee surgery, recovering at home
Chronic leg swelling /ache for years, increases while standing
Brought in by EMS
Skin is warm and slightly diaphoretic, blanching observed
Obese
98/62, spo2 98% 114, 28, 86/58 100.1
1+ pitting edema to ankles on left, 2+ edema to right knee, right calf slightly tender, left calf non-tender
A.H., 64y/o F, Hx HTN, menopause, DM, knee arthritis, cold 1 month ago, right knee replacement 6 wks
ago, presents with C/C of sudden onset of SOB worsening cough onset 3hrs ago while washing dishes.
Upon assessment pt slightly diaphoretic, skin blanching, tachypnea, tachycardia, hypoxic, BP
98/62(laying) & 85/58(standing), course lung sounds & recent cold which demonstrates sepsis related to
pneumonia w/potential r/o PE r/t recent surgery & sudden SOB
Initiating the Interview Clinician Activities
1. Announce yourself before entering the room
a. Knock and ask if the patient is ready for you to enter
2. Introduce yourself
3. Confirm the identity of your patient and ask how they would like you to referred to them
4. Disinfect your hands
5. Cover the patient and make yourself comfortable for a conversation with the patient
Comprehensive History Overview Structure of Comprehensive History:
1. Identifying Data: Name of patient, age, gender, location of the visit, reliability of person providing
the information.
2. Chief Complaint: Description of what brought the patient to seek medical attention, use the
patients words.
a. Patient is alone and reliable: Shirley Jones is a 21 y/o female who presents to clinic with
the chief complaint of….
b. Patient is alone but unreliable: Shirley Jones is a 21 y/o female who appears
disoriented/confused in clinic and presents with the chief complaint of …
c. Patient is unreliable and mother is providing the history: Shirley Jones is a 12 y/o female
who was brought to the pediatric clinic by her mother because “she appeared confused
and groggy” when her mom woke her up for school.
3. History of Present Illness:
a. Onset/setting/previous episodes ex: when did it start? What were you doing at the time?
Have you ever had this symptom before? Were you doing the same thing this time?
b. Palliation (Alleviating) factors—What makes the problem better? Ex: Food? Fasting?
Medications? Sitting? Lying down? Breathing quietly? Exercise?
c. Provocation (Aggravating) factors—What makes the problem worse? Ex. Food? Alcohol?
Stress? Exercise? Standing? Sitting?
d. Quality—What is the type of discomfort? Ex. Burning? Stabbing? Ripping? Tearing?
Suffocating?
e. Location/Radiation—Where is the problem on the body? Is it diffuse, focal, radiating?
f. Scale/Severity—How severe is the discomfort or problem on a scale of 1-10, 10 being the
worst?
g. Associated symptoms —Any other constitutional symptoms? e.g., Fever? Fatigue?
Weight loss? Weight gain? Changes in appetite? Changes in sleep patterns? Risk factors? [Show Less]