Karen Simpson iHuman Case reason for encounter Shortness of breath, Exams of Nursing

Download Karen Simpson iHuman Case reason for encounter Shortness of breath and more Exams Nursing in PDF only on Docsity! Karen Simpson iHuman Case reason for encounter Shortness of breath ise Ete eTea Asked X Not asked Graded Approach @ ccsx x Assoc Sx * Assoc Sx * ~~ Assoc Sx @ = Assoc Sx @ Assoc Sx @ = Etiotogy x Etiology Question How can | help you today? Do you ever feei/have a problem with lightheadedness? Have you been having fevers? Are you coughing up blood? Do you have any other symptoms or concerns we should discuss? Have you noticed swelling in any part of your body? Have you had any trauma to your chest? Have you been in a situation where you were sitting or lying still for a tong time? | called 911 for an ambulance hurts. Information Obtained Clinic Notes Response because | was short of breath. | felt like | might have even passed out for a second when it got bad. Alittle lightheaded right now. But when | was walking into the bus Station... | sat dawn, dialed 911 and | felt | sort of was "out of touch"... for a coupie of secands. When | came back, the lady at 911 was telling me to Stay pul, an ambulance was on its way. No. Uh...no, Yeah, | feel horrible, my chest Yes, actually | have. Uh..no, Well | just got off a long bus ride. The trip took about eight hours. | was sitting by a window and | didn't get up at all during the ride,  oye => ial EE Actually, yes. | am allergic to . that dye they give when they do @ PMH Do you have any allergies? CT tests and stuf like that. e PMH Have you ever been Yes, for my surgery five years hospitalized? ago. That's it though. Yes for blood pressure. | take e PMH Are you taking any prescription —_ two pills - Lisinopril and medications? hydrochiorothiazide. That's it as far as regular stuff. Do you now or have you ever sca al smoked or chewed tobacco? Nore. Do you use any recreational @ |s8H drugs? If so, what? Heavens: nol Do you drink alcohol? If so, what @ SH do you drink and how many | ao Si Seta A sty, drinks per day? ze Yeah. Both my parents had high blood pressure. Also my mother @ FH we ear that run Gied of a heart attack, but! don't yoy F know if anyone else died that way. Review of Systems (ROS) Select the major body systems that have not been touched on during the interview process for the HPI. @ Asked X Not asked Information Obtained Graded Question Response Clinic Notes Have you noticed any bruising, @ bleeding gums, nose bleeds, or Uh_.no. other sites of increased bleeding? Do you have problems with heat or cold intolerance, increased thirst, increased sweating, frequent urination, or change in appetite? Nope.  Do you have any problems with fatigue, difficulty sleeping, unintentional weight loss of gain, fevers, or night sweats? When you urinate, have you noticed any pain, burning, blood, difficulty starting or stopping, dribbling, incontinence, urgency during day or night, or any changes in frequency? 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, or difficulty swallowing? Have you noticed any breast discharge, lumps, scaly nipples, pain, swelling. or redness? 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, or 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, or hip pain? I'm not tired and my sleep is ok. All I can think about right now fs the trouble catching my breath, | feel ‘short of breath. What else did you ask me? Nothing wrong with my breast. What would that have to do with my problem? Uh. No joint problems or any of that. Did I tell you about my teg hurting though?  LLL Ae] ea) Exams Feedback @ Performed Correctly t * auscultate carotid arteries © You performed the simulation correctly. * auscultate heart © You performed the simulation correctly. © Your documentation was correct. © examine pupils © You performed the simulation correctly. © You documented left pupil and right pupil correctly. measure JVP (jugular venous pressure) Evaluation of the JVP |s a quick measure of cardiac function and should be done in any older individual presenting with acute SOB as a cardiac etiology must be considered. © palpate - anterior & posterior chest Evaluation of the chest MSK is important in any individual that presents with pleuritic chest discomfort. * palpate extremities Extremity palpation is done when looking for signs of occult infection, bleeds and abnormal vascular clotting. * pulse © You performed the simulation correctly. © You documented rate, rhythm, and strength correctly. © respiration © You documented rate, rhythm, and etfort correctly. * SpO, * temperature © visual inspection extremities Extremity evaluation is looking for signs of cyanosis, perfusion, trauma, infection and vascular return/edema. Case Problem Statement KS is a 63 year-old female who is brought into the ED by EMTs with the complaint of acute onset of shortness of breath following an 8 hour bus ride. She also has R sided pleuritic chest pain, and left calf swelling, On exam she has low BP (92/52 mmHg), lower than expected for a person with a diagnosis of HTN), tachycardia (116 HR), and tachypneic (28 RR), PMH positive for well controiled HTN. Risk factor is prolonged sitting.  Organize | Key Comparison to Case Findings Write @ Correct X Missed C Incorrect Problem Choice Yours Graded Seen Cardiovascular ol Select Endocrine Oo Problem Gastrointestinal oO Categories’ integumentary oOo Select Musculoskeletal oO Differential. Neurological oO Diagnosis Genitourinary/Renal Rank Respiratory a e Differential — Hematologic oa x Diagnosis Lymphatic o Select immune o Tests Psychologic oa Sexual/Reproductive [] Organize Key Findings Write Problem Statement Select Problem Categories ee) y Assessment Exam Your Differential Diagnoses Legend: @ Correct X Missed € Extraneous @ heart failure/congestive heart failure (HF/CHF) @ pneumonia @ pulmonary embolism X pericarditis X pneumothorax  Diagnosis PE a) ASTI B a Feedback Diagnosis Karen Simpson presents with a story that is very typical for the development of a pulmonary embolism. Application of the PERC rule, designed to identify patients with low probability of having a pulmonary embolism includes: Age < 50 years - Karen is 63 y/o Heart rate <100 bpm- Karen's HR is 116 bpm ‘Oxyhemoglobin saturation > 95% - Karen's is 92% No hemoptysis - Karen had none No estrogen use - Karen had none No prior DVT or PE - Karen had none No unilateral leg swelling - Karen did have unilateral leg swelling No surgery/trauma - Karen had none Patients that meet all of the 6 criteria above have low probability of pulmonary embolism. Karen only met 4. In addition, her risk factor was high due to prolonged sitting on a bus ride, the hypoxia, tachycardia and unilateral Jog swelling. Case Plan Management/Plan Pulmonary Embolism . Patient was admitted to the hospital 2. Low molecular weight heparin (enoxaparin) was started (Ima/kg q 12h SQ and continued for 5 days until INR is therapeutic Coumadin was started to try to achieve an INR of 2.0-3.0 - will continue for total of 6 months 1. O02 2 LNP as needed Continued ambulation Recommended for further cancer screening (colonoscopy, pap smear, mammogram) to ensure occult malignancy was not contributory to the development of her PE PnaRe Hypotension 1, BP meds were held until evidence of elevated BP 2. IV hydration (1/2 NS ) was started to treat her low BP