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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Case: 165484 Karen Barnes
Date: 03/06/2021
FamHx
Grandparents (if known)/Parents/siblings/children
Father died at age 65 of stroke
Mother died at age 54 with heart disease
Older sister age 58: recent open-heart surgery
SHx
Tobacco/vaping/ETOH/illicit drug use/occupational/environmental/relationships
ETOH: Drinks 1-2 glasses of wine each night
Tobacco: Previous smoker: Quit 15 years ago
Denies use of recreational drugs
Patient reports a very stressful job
Reproductive Hx
Female: Age of menarche/menstruation cycle
duration/gravida para status/Childbirth hx/sexual hx and
concerns/LMP/menopause
Breast/cervical screening (if any)
Male: Sexual hx and concerns/issues with fertility (if
any)/Testicular or prostate screening (if applicable)
Screening for STI’s (if applicable)
Up to date for cancer screening for gender.
Annual gynecological exam normal
Not currently sexually active
Allergies (Food, Drug, Environmental, etc.)
No known allergies
List of Medications/supplements (prescription, OTC, complementary
alternative therapies)
Hydrochlorothiazide 12.5mg daily
Review of Systems: (ROS) Use this column to
document the ROS below.
General: Chest pain with dyspnea, denies
fatigue, weakness, sleep disturbance
HEENT: No complaint of headache, vision
problem, ear pain or sinus problems
Pulmonary: shortness of breath with exertion,
denies wheezing
From the ROS: list/highlight the current symptoms/complaints to generate
a list of pertinent “reported or denied” symptoms below:
Pertinent Positive ROS: Chest pain middle chest that radiates to left arm, history
of hypertension and high cholesterol, Dyspnea with exertion
Pertinent Negative ROS: Denies wheezing, or recent change in sleep pattern,
denies change in diet, no complaint of nausea/vomiting/diarrhea or change in
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Case: 165484 Karen Barnes
Date: 03/06/2021
CV: Chest pain middle chest that radiates to left
arm, history of hypertension and high
cholesterol
GI: No complaint of
nausea/vomiting/diarrhea/decrease in appetite or
diet
GU: No complaint of urinary problems
MS: No recent trauma or injury
Heme: No sign bruising
Lymph: No complaint
Endocrine: No history of endocrine disorder
Derm: No signs of rash
Neuro: no complaint of dizziness, fainting,
weakness
Psych: Denies depression or anxiety
diet or appetite
Physical Exam: (PE) Use this column to
document the PE below.
Vitals (HR/BP/RR/T/SpO2/Ht/Wt/BMI%)
HR: 72, BP 134/88, RR: 16, SPO2: 96%, Height: 5ft
6 inches, Weight: 158lbs., BMI: 25.5
General: Female with no current sign of distress
HEENT: Normocephalic, atraumatic, no
deformities, face symmetrical, Pupils normal and
reactive
Neck: No visible scars or deformities or lesions
Pulm Respirations regular and unlabored, normal
lung sounds, negative for wheezing.
CV: Normal heart sounds, HR 85 NO JVD, PMI
nondisplaced
From the PE: list/highlight the presence or absence of objective findings to
generate a list of pertinent “(+) or (-)” symptoms below:
Pertinent Positive PE findings: Elevated BP
Pertinent Negative PE Findings: Normal heart sounds, HR 85 NO JVD, PMI
nondisplaced, BMI 25.5
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Case: 165484 Karen Barnes
Date: 03/06/2021
GI: abdomen not tender and bowel sounds present in
all 4 quadrants
GU: negative for any urinary problems
Neuro: Alert and oriented X 4
Derm: Skin turgor normal. Skin warm and dry with
no lesions
MSK: Normal bulk and tone
Psych: Not assessed
Lab/Radiology or other Diagnostic data:
12 lead electrocardiograms: Normal sinus
rhythm, no ST elevation abnormalities
Troponin T: within normal values
CBC: all labs within normal values
Lipid profile: elevated cholesterol, and elevated
LDL cholesterol
Blood glucose: normal
Cardiac stress test: ST segment depression
Echocardiogram: Normal cardiac structure and
function
CK-MB: Normal
Problem Statement:
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. She has a history of
hyperlipidemia and hypertension. She has a previous history of smoking and a
family history of coronary vascular disease. She is slightly overweight; the
remainder of exam is unremarkable. Physical examination indicated elevated BP.
EKG is normal with no ST elevation abnormalities. Troponin, CBC, lipid
profile, CK-MB were normal
IHUMAN TOTAL CASE SCORES:
#1: 71%
#2: 95%
Based on patient’s age/risk factors, what
List the differential diagnoses (Must not
Miss/Leading/Alternate/Concluding)
*Include ICD 10 codes after each
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Case: 165484 Karen Barnes
Date: 03/06/2021
preventive screening would be recommended
at today’s or a future visit:
Grade A Recommendations:
High Blood Pressure adults over age 18. Check
periodically for evidence of elevated b/p
readings (slightly elevated b/p likely related to
pain)
Cervical cancer screening for women aged 21-
65 years
Grade B RecommendationsScreening for Depression/Mood Disorders in
adults (reports stress at today’s visit)
Healthy diet and physical activity for prevention
of CVD in adults with risk factors
Skin Cancer prevention annually
Screening for unhealthy alcohol/drug use in
adolescents/adults
Screening for type 2 diabetes in adults aged 40
to 70 years who are overweight or obese
(USPSTF, 2021)
Must Not Miss/Leading:
Stable Angina (I20.9): Chest pain and dyspnea with exertion that is relieved at
rest.
Unstable Angina (120.0): The recurrent chest pain was stable and not
representative of unstable angina
Alternate:
Esophageal spasm (K22.4): symptoms mimic anginal chest pain, but not
indicative for Ms. Barnes
Gastroesophageal reflux (K21.9): The exertional quality of the patient’s
symptom rules out GERD
Costochondritis (M94.0): Patient did not complain of symptoms indicative of
this diagnosis
Concluding:
Stable Angina (I20.9): The subacute nature of chest pain and dyspnea more
indicative of stable (Gillen, 2020).
*Case Study Template adapted from the following sources: NP H & P (ReNursing.edu, 2018) and IHuman Patients b [Show Less]