Week #4: Assignment: Assessing, Diagnosing, and Treating Conditions of the Cardiovascular System 2
(NRNP 6550: Advanced Care of Adults in Acute
... [Show More] Settings II)
i-Human
198142 Alvin Stafford V6 PC
Advanced Practice Care of Adults in Acute Care Settings II
HPH:
Yearly physical
Mr. Stafford is a 63-year-old male with an 94 pack-year history of smoking and medical history of COPD here for his yearly physical. No new complaints noted.
PHH:
• COPD x 20+ years
• None
• Minimal exercise
• American diet
• Colonoscopy at age 55
• Yearly flu vaccine at local pharmacy
Family Hx:
• Father died at 53 from MI
• Mother died at 65 from pancreatic cancer
• Brother had partial pneumonectomy, possible lung cancer
Social Hx:
• Began smoking age 16; smokes 2 packs (filtered) per day; has never considered quitting
• Former heavy alcohol use; now 1 to 2 beers daily, CAGE negative
• No recreational drugs
• Lives alone, wife died 4 years ago, no children
• No pets
• Worked a desk job all of his life, retired
• College-educated
• Uses seat belts
Observations: warm and sweaty (Provided by i-Human module)
NOTES FROM i-HUMAN ASSESSMENT:
1) How can I help you today? I get out of breath really easily
2) When did your fatigue/tiredness start? I don’t have that problem.
3) When did you first notice feeling short of breath? I started feeling more and more out of breath 2 days ago.
4) What are the events surrounding the start of your difficulty breathing? It’s not difficult as much as being SOB.
5) Do you have any other symptoms or concerns we should discuss? Yeah, I’m coughing more than my normal smoker’s cough.
6) Are you coughing up any sputum? Yeah, I’ve coughed in the morning and brought up white stuff for years. I am used to it. Its not much; maybe a spoonful at most. Then I’d be fine for the rest of the day. The last few days It’s been something else though. Its nasty. Do you really want to know more?
7) What does your sputum look like? Nasty, yellow-greenish gunk.
8) Does anything make your cough better or worse? Well, going up the stairs makes it
worse. Definitely. Can’t figure out how to make it better
9) What treatments have you had for your cough? Nothing
10) Do you have any pain, or any other symptom associated with your cough? Nothing that I have not told you.
11) Can you tell me about any current or past medical problems you have had? I feel sick
12) Any previous medical, surgical, or dental procedures? Nothing other than the colonoscopy I had a few years back.
13) When was your last physical? I think about 3 months ago. You could look it up in my chart to know for sure.
14) Do you have COPD? Yes, for a number of years.
15) Do you now or have you ever smoked or chewed tobacco? Yep, cigarettes my whole life, or just about. May be 50 years or so. And, no, I’ve never considered quitting. Period.
16) Have you ever been hospitalized? No.
17) Do you experience chest pain discomfort or pressure; pain, pressure, dizziness with exertion or getting angry; palpitations; decrease exercise tolerance; blue/cold fingers and toes? No, none of that stuff except the exercise. I can’t do much of that now.
18) Do you become SOB with exertion? Pretty quick when I do heavy stuff
19) Have you been having fevers? Not that I have noticed. I think they checked my temperature when I came in. Don’t know what it was.
20) Do you have high blood pressure? I do not think so.
21) Are you SOB when lying down? Not really.
22) Do you sleep with a pillow to help you breath? No
23) Do you have nigh sweats? No.
24) How is your health overall? I have noticed over the last couple of years that I cannot
do things as quickly as I used to, but I just figured its just “old age”
25) Do you have any sensation of a “pounding heart” in your chest? No
Hint:
11/24 key questions remain. 5 more in Associated Sx
2 more with HPI 2 more with PMH
1 more with Etiology 11 more with ROS
26) Do you experience shortness of breath, wasting, difficulty catching your breath, chronic cough, or sputum production? This is why I am here to see you.
27) Do you drink alcohol? If so, what do you drink and how many drinks per day? A couple of beers a day.
28) Do you have any problems with an itchy scalp, skin changes, moles, thinning hair, or brittle nails? Uh… no
29) Have you ever had an EKG? No.
30) Do you have any allergies? No that I know of.
31) Do you have any problems with nausea, vomiting, constipation, diarrhea, coffee grounds in your vomit, dark tarry stools, bright red blood in your bowel movements, early satiety, or bloating? No.
32) When you urinate, have you noticed any pain, burning, blood, difficulty starting or stopping, driveling, incontinence, urgency during the day or night, or changes in frequency? No.
33) 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, or hip pain? Maybe I am lucky, but I don/t seem to have a lot of joint problems.
34) Have you noticed any bruising, bleeding gums, nosebleeds, or other sites of increased leading? Nope.
35) Do you have problems with heat or cold intolerance, increased thirst, increased sweating, frequent urination, or changes in appetite? No problems with heat or cold in particular or thirst. Now what else was it you needed to know?
36) Do you have any problems with dizziness, fating, spinning room, seizures, weakness, numbness, tingling, or tremor? None of those things.
37) Do you have any problems with nervousness, depression, lack of interest, sadness, memory loss, or mood changes, or ever heard voices or seen things that you know were not there? Uh… no.
38) Do you have any problems with headaches that don’t go away with aspirin or Tylenol, double or blurred vision, difficulty with night vision, problems hearing, ear pain, sinus problems, chronic sore throats, or difficulty swallowing? No headaches or anything. Sinus problems. Not now, but my nose felt stuffy, and I had a lot od nasal stuff about two weeks ago. I was also sneezing more than usual.
39) Do you have a runny nose or nasal congestion? Not now, but my nose felt stuffy and I had a lot of loose nasal stuff about two weeks ago. I was also sneezing more than usual. I do not have that problem now.
40) What childhood illnesses have you had? The usual cough, colds and tummy aches. Nothing remarkable.
41) Are you taking any prescription medications? No. I stay away from everything except the flu shots.
42) Can you tell me about your diet? What do you normally eat? Seems fine to me.
Hint:
20/24 key questions remain.
3 more in CC Sx and Sx characteristics 5 more in Associated Sx
2 more with HPI 2 more with PMH
1 more with Etiology 2 more with ROS Efficiency % is 26%
43) Do you awaken at night with cough? Yes, just recently I have.
44) What are the events surrounding your cough? I do not know that there was an event really.
45) Does your cough come and go? Well, I am not coughing continuously, but I am coughing more than just in the morning.
46) Have you gained or lost weight unintentionally, despite normal appetite and exercise? I might have lost a couple of pounds in the last few days, but my weight has been pretty much the same for years.
47) Do you cough after swallowing? No.
48) Do you have any problems with fatigue, difficulty sleeping, unintentional weight loss or gain, fevers, or night sweats? Maybe I am a little worn out from the SOB, but its not my main concern. What else is it that you want to know.
49) What symptom is the most distressing for you? The breathing. I get out of breath doing the least little things.
50) Do you have HIV? Nope.
51) Have you had any significant traumatic injuries or accidents? No.
52) Have you ever been treated for blood clits? (have a Hx of thrombolytic or anticoagulation therapy?) Nope.
53) Do you have a history of heart failure? No.
54) Do you have any other symptoms associated with your fatigue/tiredness? I don’t
really have that problem.
55) How severe is your cough? I’ve been used to the morning cough. Had it for years, but
this new one is problem for me.
56) What are the events surrounding the start of your shortness of breath? I can’t think
of any particular event.
57) Does anything make your SOB better or worse? I’m out of breath with any exertion. Just going up a few stairs to mt bedroom does it. That’s new for me; usually I can do the stairs fine. It takes 5-10 minutes for it go get better. But now it never really goes [Show Less]