IHUMAN Case Study
Perpetual Anita Aseme
IHUMAN CASE # 3: Cardiovascular Karen Barnes
NURS5342
Advanced Health Assessment
March 6, 2021
This study
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Case: 165484 Karen Barnes
Date: 03/06/2021
Instructions: Type patient encounter information directly into each box of the template. Students should avoid the use of the following terms:
“WNL”/”Normal”, etc and should document systems with specificity and accuracy. Students are also expected to incorporate any feedback faculty have
provided on previous cases into each subsequent assignment.
CC: 49-year-old female
Chief complaint is a short 1-2 statement or word phrase
from patient and should be listed in “quotes”
“Exertional mid-chest pain that radiates to left
arm with a squeezing quality”
HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts
Ms. Barnes is a 49-year-old female with chest pain and dyspnea that started 2
weeks ago during a ski run activity in the cold. She reports that the chest pain
radiates to the left arm and has a squeezing quality to it. The pain is exacerbated
by fast walking in the cold and relieved by resting.
Onset: Chest pain 2 week ago during a cross-country ski run
Location: Mid chest that radiates to left arm
Duration: The chest pain comes and goes. Lasts several minutes and occurs1-2
times a week
Character: Chest pain with a squeezy quality and radiates to the left arm. Pain
scale of 5 or 6 on scale of 1-10
Aggravating/alleviating factors: Precipitated by exercise and improves with
rest
Related symptoms: Dyspnea that occurs with chest pain with exertion
Treatments: Nothing
Significance: Chest pain in someone with her medical and family history can
indicate a serious problem
PMHx child/adult
illness/hospitalizations/immunizations
History of hypertension and high cholesterol
Missed this year’s flu vaccination
SurgHx type/when/why/complications
No surgical history
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