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Ihuman-CASE-STUDY =ARIELA 1 1
HERNANDEZ ACUTE ONSET 1
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DYSPNEA AND SYNCOPE
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with 4 different version march
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2025
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Ariela Hernandez Acute onset dyspnea and syncope iHuman case
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study essay 1 1
6 4 years5-3
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2 0 pounds Ariela
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Hernandez 1
Chief complaint:
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Acute onset dyspnea and near syncope
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,1
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Mrs. Hernandez is a 64 year old obese female with HTN, current smoker f
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,1
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or1the1past1401years,1diabetes,1right1knee1replacement1surgery161weeks1ag
o,1complaints1of1acute1onset1dyspnea1and1near1syncope1started1approxi
mately131hours1ago.1Associated1symptoms1SOB,1cough,1right1calf1slightly
1tender1and1swollen.1Physical1examination1demonstrates1signs1of1possibl
e1PE.1
Trace to 1+ edema to ankles on left, 2+ edema to knee on right, well hea
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ling incisional scar overlying right knee from recent surgery slightly swoll
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en compared to left right calf slightly tender, left calf non tender, no left j
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oint swelling or erythema, no clubbing or cyanosis, extremities are well p
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erfused Ariela Hernandez Acute onset dyspnea and syncope iHuman cas
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e study essay.
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Abdomen-
normal, no tenderness, no masses appreciated, liver of normal size, sm
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ooth edge palpable, spleen normal
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Note the three tabs: 1) current visit (blank EMR), 2) Pt. Info Forms
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(contains Vital Signs for current visit) and 3) 1 month ago (contains recor
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ds from outpatient surgical visit 1 month ago). These tabs provide vital in
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formation. 1
For this case there are 22 required history questions:
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(CC (2), HPI/Symptom+ Assoc. Symptoms (10),
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PMH/Surg/Hosp/Meds/Environment (4), Allergies (1), FH (0), SH (0), Pr 1 1 1 1 1 1 1 1
evention/Risk Behaviors (0), ROS (5). 1 1 1 1 1
History Questions 1 1
Ariela1Hernandez1is1an1Acute1onset1dyspnea1and1syncope1iHuman1case1study1essay1The1
history1questions1to1ask1Ariela1Hernandez1are:1
1.1Where1do1you1live?1
2.1Do1you1have1any1children,1spouse,1or1partner?1
3.1Do1you1smoke?1
4.1How1many1years1have1you1been1smoking?1
5.1How1much1do1you1smoke1a1day?1
6.1Do1you1have1any1history1of1lung1disease?1
7.1Do1you1have1asthma?1