Week #4: Assignment: Assessing, Diagnosing, and Treating
Conditions of the Cardiovascular System 2
(NRNP 6550: Advanced Care of Adults in Acute Settings II)
i-Human
198142 Alvin Stafford V6 PC
Advanced Practice Care of Adults in Acute Care Settings II
Note from 3 months ago (Provided by i-Human module)
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
Conditions of the Cardiovascular System 2
(NRNP 6550: Advanced Care of Adults in Acute Settings II)
i-Human
198142 Alvin Stafford V6 PC
Advanced Practice Care of Adults in Acute Care Settings II
Note from 3 months ago (Provided by i-Human module)
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
