LATEST UPDATED 2024 ARIELA HERNANDEZ ACUTE ONSET
DYSPNEA AND SYNCOPE IHUMAN CASE STUDY ESSAY
64 years5′
3″
200 pounds Ariela
Hernandez
Chief
... [Show More] complaint:
Acuteonset dyspnea and near syncope
Mrs. Hernandez is a 64 year oldobese 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
recordsfrom outpatientsurgicalvisit 1 monthago).These tabs provide vital information.
For this case there are22 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 iHumancase study essayThe 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 aday?
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.Areyou taking any prescription medications?
11.Areyou taking any over the counter or herbal medications?
12.Do you drink alcohol? If so, whatdo youdrink and how manydrinks per day?
13.Do you take insulin fordiabetes?
14.Do youdrink caffeinated beverages or eat chocolate?
15.Tell meabout your diet, what you normallyeat?
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.Areyou coughing up any sputum?
19.Is there any pattern to your cough?
20.What treatments haveyouhad 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,hippain?
23.Haveyouever been hospitalized?
24.hat kindof work do youdo?
25.Do you haveany allergies??
26.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
27.Have you noticed: any bruising, bleeding gums or other sites of increased bleeding?
28.Do you have any of the following: heat or cold intolerance, increased thirst, sweating,
frequent urination, change in appetite?
29.Do you have any of the following: dizziness, fainting, spinning room, seizures,
weakness, numbness, tingling, tremor?
30.Is therea pattern to when you havedifficultybreathing?
31.Do you haveany pain inyour chest?
32.Does your chest feel tight or heavy?
33.Do you have any of the following problems: fatigue, difficulty sleeping,unintentional
weight loss or gain, fevers, night sweats?
34.Do you have any problems with: itchy scalp, skin changes, moles, thinning hair,
brittle nails?
35.Have youbeen ina situation whereyou weresitting or lying still for a long time?
36.Areyou short ofbreath whenlyingdown?
37.Do you awaken at night short of breath?
38.Do youhaveunusual heartbeats (palpitations)?
39.Do yousleep withpillows tohelp youbreathe?
40.Do you feel as if you aresmothering or suffocating?
41.Do you wheeze?
42.Anyprevious medical surgical, ordental procedures?
43.Have you ever had this illness before?
44.Do you havepainanywhere, if so where?
45.What is the most distressing symptom for you?
46.Has your level of activity recently changed?
47.Areyou in good spirits most of the time?
48.Does anything make your difficulty breathing better or worse?
49.Does anything make your cough better or worse? [Show Less]