Ariela Hernandez Acute onset dyspnea and syncope iHuman case study (4 Different Versions), Exams of Nursing

Download Ariela Hernandez Acute onset dyspnea and syncope iHuman case study (4 Different Versions) and more Exams Nursing in PDF only on Docsity! Monday, October 16, 2023 1 Ariela Hernandez Acute onset dyspnea and syncope iHuman case study (4 Different Versions) Latest Updated 2023 Ariela Hernandez Acute onset dyspnea and syncope iHuman case study essay 64 years 5′ 3″ 200 pounds Ariela Hernandez Chief complaint: Acute onset dyspnea and near syncope Mrs. Hernandez is a 64 year old obese 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 Monday, October 16, 2023 2 records from outpatient surgical visit 1 month ago). These tabs provide vital information. For this case there are 22 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 iHuman case study essay The 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 a day? 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. Are you taking any prescription medications? 11. Are you taking any over the counter or herbal medications? 12. Do you drink alcohol? If so, what do you drink and how many drinks per day? 13. Do you take insulin for diabetes? 14. Do you drink caffeinated beverages or eat chocolate? 15. Tell me about your diet, what you normally eat? 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. Are you coughing up any sputum? 19. Is there any pattern to your cough? 20. What treatments have you had 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, hip pain? 23. Have you ever been hospitalized? 30. Is there a pattern to when you have difficulty breathing? 31. Do you have any pain in your 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? 29. Do you have any of the following: dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, tremor? 1. HISTORY. Decide of this is a patient that can be treated as an outpatient; focused case – fewer history questions needed versus a patient who might be hospitalized for treatment (comprehensive case) where all components of a history. o Document abnormal findings in your problem list. o There is no penalty for doing more than what is required. This is worth 40% of your overall case play score. 2. Proceed to perform a PHYSICAL ASSESSMENT. Assess vital signs and perform the examination appropriate for the type of case identified by the above history. Ariela Hernandez Acute onset dyspnea and syncope iHuman case study essay. Remember the comprehensive cases require a comprehensive physical. o Document abnormal findings in your problem list. o There is no penalty for doing more than what is required. This is worth 40% of your overall case play score. 34. Do you have any problems with: itchy scalp, skin changes, moles, thinning hair, brittle nails? 35. Have you been in a situation where you were sitting or lying still for a long time? 36. Are you short of breath when lying down? 37. Do you awaken at night short of breath? 38. Do you have unusual heartbeats (palpitations)? 39. Do you sleep with pillows to help you breathe? 40. Do you feel as if you are smothering or suffocating? 41. Do you wheeze? 42. Any previous medical surgical, or dental procedures? 43. Have you ever had this illness before? 44. Do you have pain anywhere, if so where? 45. What is the most distressing symptom for you? 46. Has your level of activity recently changed? 47. Are you 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? 50. Do you have a problem with fatigue? 3. Complete the PROBLEM LISTexercise, pick those problems that match what you have on your problem list. o This is worth 20% of your overall case play score. 4. Write a concise problem statement. Start with a demographic description of your patient and the chief complaint and MSAP. Try to keep your problem statement below 100 words. Asked questions: what is your name how old are you where are you where do you live where and with whom are you living do you have any children, spouse, Significant partner do you practice any religion why are you seeking help today any other symptoms how many years have you been smoking how much do you smoke a day do you have any history of lung disease do you have asthma do you use any recreational drugs how is your overall health tell me about any current or past medical problems are your immunizations up to date are you taking any prescription medications are you taking any over the counter or herbal medications Ariela Hernandez Acute onset dyspnea and syncope iHuman case study essay Do you drink alcohol? If so, what do you drink and how many drinks per day do you take insulin for diabetes Has anyone suggested that you should reduce the amount of alcohol you drink Do you drink caffeinated beverages or eat chocolate Tell me about your diet, what you normally eat complaint is physical therapy is harder than she expected and she still has residual pain. She continues to smoke against our recommendations. O: VS normal. Surgical scar healing well without signs of infection. Lungs clear, Heart RRR w/o murmur, Abd soft and non-tender, Neuro reflexes x 2 throughout, MSK right knee healing well. A: Normal recovery for right-knee replacement in obese type 2 diabetic patient who continues to smoke. P: Continue physical therapy, f/u PCP for diabetes management, continue to encourage weight loss and stress need for ambulation Q2 hours throughout waking hours. Continue to stress the importance of smoking cessation. Ariela Hernandez Acute onset dyspnea and syncope iHuman case study essay. 2nd Version Mrs. Hernandez is a 64 year old obese 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. Abdomen- normal, no tenderness, no masses appreciated, liver of normal size, smooth edge palpable, spleen normal At the start of the case click on “Show Patient Record, above the Problem List Icon. 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 records from outpatient surgical visit 1 month ago). These tabs provide vital information. You must receive an overall score greater than or equal to 80% to have mastered this course. For this case there are 22 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). 1. Take the patient’s HISTORY. ▪ Decide of this is a patient that can be treated as an outpatient; focused case – fewer history questions needed versus a patient who might be hospitalized for treatment (comprehensive case) where all components of a history. o Document abnormal findings in your problem list. o There is no penalty for doing more than what is required. This is worth 40% of your overall case play score. 2. Proceed to perform a PHYSICAL ASSESSMENT. ▪ Assess vital signs and perform the examination appropriate for the type of case identified by the above history. Ariela Hernandez Acute onset dyspnea and syncope iHuman case study essay. Remember the comprehensive cases require a comprehensive physical. o Document abnormal findings in your problem list. o There is no penalty for doing more than what is required. This is worth 40% of your overall case play score. 3. Complete the PROBLEM LIST exercise, pick those problems that match what you have on your problem list. o This is worth 20% of your overall case play score. 4. Write a concise problem statement. ▪ Start with a demographic description of your patient and the chief complaint and MSAP. Try to keep your problem statement below 100 words. Asked questions: what is your name how old are you where are you where do you live where and with whom are you living do you have any children, spouse, Significant partner do you practice any religion why are you seeking help today any other symptoms how many years have you been smoking how much do you smoke a day do you have any history of lung disease do you have asthma do you use any recreational drugs how is your overall health tell me about any current or past medical problems are your immunizations up to date are you taking any prescription medications are you taking any over the counter or herbal medications Ariela Hernandez Acute onset dyspnea and syncope iHuman case study essay Do you drink alcohol? If so, what do you drink and how many drinks per day do you take insulin for diabetes Has anyone suggested that you should reduce the amount of alcohol you drink Do you drink caffeinated beverages or eat chocolate Tell me about your diet, what you normally eat 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 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 Are you coughing up any sputum Is there any pattern to your cough What treatments have you had for your cough 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 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, hip pain Have you ever been hospitalized Tell me about your work Do you have any allergies 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 Have you noticed: any bruising, bleeding gums or other sites of increased bleeding Do you have any of the following: heat or cold intolerance, increased thirst, sweating, frequent urination, change in appetite Ariela Hernandez Acute onset dyspnea and syncope iHuman case study essay Do you have any of the following: dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, tremor Is there a pattern to when you have difficulty breathing Do you have any pain in your chest 4th Version Ariela Hernandez Chief complaint: Acute onset dyspnea and near syncope Mrs. Hernandez is a 64 year old obese 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. More History Questions Ariela Hernandez is an Acute onset dyspnea and syncope iHuman case study essay The history questions to ask Ariela Hernandez are: Step-by-step explanation S: Mrs. Hernandez is a 64-year-old woman who is here for routine follow-up 2 weeks s/p right knee replacement. Ariela Hernandez Acute onset dyspnea and syncope iHuman case study essay. Her only complaint is physical therapy is harder than she expected and she still has residual pain. She continues to smoke against our recommendations. O: VS normal. Surgical scar healing well without signs of infection. Lungs clear, Heart RRR w/o murmur, Abd soft and non-tender, Neuro reflexes x 2 throughout, MSK right knee healing well. A: Normal recovery for right-knee replacement in obese type 2 diabetic patient who continues to smoke. P: Continue physical therapy, f/u PCP for diabetes management, continue to encourage weight loss and stress need for ambulation Q2 hours throughout waking hours. Continue to stress the importance of smoking cessation. Ariela Hernandez Acute onset dyspnea and syncope iHuman case study essay. Step-by-step explanation Reference Groven, F. M., Zwakhalen, S. M., Odekerken Schröder, G., Tan, F., & Hamers, J. P. (2021). Comfort during the bed bath—A randomised crossover trial on the effect of washing without water versus water and soap in nursing students. Journal of clinical nursing, 30(15-16), 2234- 2245. 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 a day? 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. Are you taking any prescription medications? 11. Are you taking any over the counter or herbal medications? 12. Do you drink alcohol? If so, what do you drink and how many drinks per day? 13. Do you take insulin for diabetes? 14. Do you drink caffeinated beverages or eat chocolate? 15. Tell me about your diet, what you normally eat? 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. Are you coughing up any sputum? 19. Is there any pattern to your cough? 20. What treatments have you had 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, hip pain? 23. Have you ever been hospitalized? 24. hat kind of work do you do? 25. Do you have any 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 there a pattern to when you have difficulty breathing? 31. Do you have any pain in your 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? Step-by-step explanation Ariela Hernandez is an Acute onset dyspnea and syncope iHuman case study essay Mrs. Ariela Hernandez is a 64 year old obese 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 . She is 5′ 3″ and weighs 200 pounds. Asking her history questions will provide you as the healthcare professional with an accurate medical history and helps you get a better understanding of Ariela's health issues. and allows you to identify patterns and make more effective decisions based on Ariela's specific health needs. The 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 a day? 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. Are you taking any prescription medications? 11. Are you taking any over the counter or herbal medications? 12. Do you drink alcohol? If so, what do you drink and how many drinks per day? 13. Do you take insulin for diabetes? 14. Do you drink caffeinated beverages or eat chocolate? 15. Tell me about your diet, what you normally eat? 34. Do you have any problems with: itchy scalp, skin changes, moles, thinning hair, brittle nails? 35. Have you been in a situation where you were sitting or lying still for a long time? 36. Are you short of breath when lying down? 37. Do you awaken at night short of breath? 38. Do you have unusual heartbeats (palpitations)? 39. Do you sleep with pillows to help you breathe? 40. Do you feel as if you are smothering or suffocating? 41. Do you wheeze? 42. Any previous medical surgical, or dental procedures? 43. Have you ever had this illness before? 44. Do you have pain anywhere, if so where? 45. What is the most distressing symptom for you? 46. Has your level of activity recently changed? 47. Are you 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? 50. Do you have a problem with fatigue?