n
Ariela Hernandez Acute onset dysp n n n n
nea and syncope iHuman casestudy n n n n n n
(4 Different Versions) n n
Ariela Hernandez Acute onset dyspnea and syncope iHuman casestud
n n n n n n n n n
y essay n
64 years n n
5′ 3″ n n
200 pounds Ariel n n
a Hernandez
n
Chief complaint: n
Acute onset dyspnea and near syncope
n n n n n
Mrs. Hernandez is a 64 year old obese female with HTN, current smokerfor
n n n n n n n n n n n n n n
the past 40 years, diabetes, right knee replacement surgery 6 weeksago, c
n n n n n n n n n n n n
omplaints of acute onset dyspnea and near syncope started approximate
n n n n n n n n n
ly 3 hours ago. Associated symptoms SOB, cough, right calf slightly tend
n n n n n n n n n n n
er and swollen. Physical examination demonstrates signs of possible PE.
n n n n n n n n n
Trace to 1+ edema to ankles on left, 2+ edema to knee on right, well healin
n n n n n n n n n n n n n n n
g incisional scar overlying right knee from recent surgery slightlyswollen
n n n n n n n n n n n
compared to left right calf slightly tender, left calf non tender,no left join
n n n n n n n n n n n n n
t swelling or erythema, no clubbing or cyanosis, extremities are well perfu
n n n n n n n n n n n
sed Ariela Hernandez Acute onset dyspnea and syncopeiHuman case stud
n n n n n n n n n n
y essay.
n
Abdomen-
normal, no tenderness, no masses appreciated, liver ofnormal size, smoot
n n n n n n n n n n n
h edge palpable, spleen normal
n n n n
Note the three tabs: 1) current visit (blank EMR), 2) Pt. Info Forms (contains
n n n n n n n n n n n n n n
Vital Signs for current visit) and 3) 1 month ago (contains
n n n n n n n n n n
n
,n
records from outpatient surgical visit 1 month ago). These tabs providevital i
n n n n n n n n n n n n
nformation.
For this case there are 22 required history questions:(C
n n n n n n n n n
C (2), HPI/Symptom+ Assoc. Symptoms (10),
n n n n n
PMH/Surg/Hosp/Meds/Environment (4), Allergies (1), FH (0), SH (0),
n n n n n n n
Prevention/Risk Behaviors (0), ROS (5).
n n n n
History Questions n
ArielanHernandeznisnannAcutenonsetndyspneanandnsyncopeniHumanncasenstudynessaynThe
nhistorynquestionsntonasknArielanHernandeznare:n
1. Wherendonyounlive?n
2. Donyounhavenanynchildren,nspouse,nornpartner?n
3. Donyounsmoke?n
4. Hownmanynyearsnhavenyounbeennsmoking?n
5. Hownmuchndonyounsmokenanday?n
6. Donyounhavenanynhistorynofnlungndisease?n
7. Donyounhavenasthma?n
8. Donyounusenanynrecreationalndrugs?n
9. Tellnmenaboutnanyncurrentnornpastnmedicalnproblems.n
10. Arenyountakingnanynprescriptionnmedications?n
11. Arenyountakingnanynovernthencounternornherbalnmedications?n
12. Donyoundrinknalcohol?nIfnso,nwhatndonyoundrinknandnhownmanyndrinksnpernday?n
13. Donyountakeninsulinnforndiabetes?n
14. Donyoundrinkncaffeinatednbeveragesnorneatnchocolate?n
15. Tellnmenaboutnyourndiet,nwhatnyounnormallyneat?n
16. Donyounhavenanynproblemsnwith:nnervousness,ndepression,nlacknofninterest,nsadne
ss,nmemorynloss,nornmoodnchanges,nornevernhearnvoicesnthatnyounknownarennotnthe
re?n
17. Whennyounurinate,nhavenyounnoticed:npain,ndifficultynstartingnornstopping,ndribbling,ni
ncontinence,nurgencynduringndaynornnight.nAnynchangesninnfrequency?nAnynbloodninn
yournurine?n
18. Arenyouncoughingnupnanynsputum?n
19. Isntherenanynpatternntonyourncough?n
20. Whatntreatmentsnhavenyounhadnfornyourncough?n
21. Donyounhavenproblemsnwith:nnausea,nvomiting,nconstipation,ndiarrhea,ncoffeen
groundsninnyournvomit,ndarkntarrynstool,nbrightnrednbloodninnyournbowelnmovem
ents,nearlynsatiety,nbloating?n
22. Donyounhavenproblemsnwith:nmusclenornjointnpain,nredness,nswelling,nmusclencr
amps,njointnstiffness,njointnswellingnornredness,nbacknpain,nnecknornshouldernpa
in,nhipnpain?n
23. Havenyounevernbeennhospitalized?n
n
, n
24. hatnkindnofnworkndonyoundo?n
25. Donyounhavenanynallergies??n
26. Donyounhavenanynproblemsnwith:nheadachesnthatndon'tngonawaynwithnaspirinnorn
Tylenoln(acetaminophen),ndoublenornblurrednvision,ndifficultynwithnnightnvision,np
roblemsnhearing,nearnpain,nsinusnproblems,nchronicnsorenthroats,ndifficultynswall
owingn
27. Havenyounnoticed:nanynbruising,nbleedingngumsnornothernsitesnofnincreasedn
bleeding?n
28. Donyounhavenanynofnthenfollowing:nheatnorncoldnintolerance,nincreasednthirst,n
sweating,nfrequentnurination,nchangeninnappetite?n
29. Donyounhavenanynofnthenfollowing:ndizziness,nfainting,nspinningnroom,nseizures,n
weakness,nnumbness,ntingling,ntremor?n
30. Isntherenanpatternntonwhennyounhavendifficultynbreathing?n
31. Donyounhavenanynpainninnyournchest?n
32. Doesnyournchestnfeelntightnornheavy?n
33. Donyounhavenanynofnthenfollowingnproblems:nfatigue,ndifficultynsleeping,n
unintentionalnweightnlossnorngain,nfevers,nnightnsweats?n
34. Donyounhavenanynproblemsnwith:nitchynscalp,nskinnchanges,nmoles,nthinningnhair,n
brittlennails?n
35. Havenyounbeenninnansituationnwherenyounwerensittingnornlyingnstillnfornanlongntime?n
36. Arenyounshortnofnbreathnwhennlyingndown?n
37. Donyounawakennatnnightnshortnofnbreath?n
38. Donyounhavenunusualnheartbeatsn(palpitations)?n
39. Donyounsleepnwithnpillowsntonhelpnyounbreathe?n
40. Donyounfeelnasnifnyounarensmotheringnornsuffocating?n
41. Donyounwheeze?n
42. Anynpreviousnmedicalnsurgical,norndentalnprocedures?n
43. Havenyounevernhadnthisnillnessnbefore?n
44. Donyounhavenpainnanywhere,nifnsonwhere?n
45. Whatnisnthenmostndistressingnsymptomnfornyou?n
46. Hasnyournlevelnofnactivitynrecentlynchanged?n
47. Arenyouninngoodnspiritsnmostnofnthentime?n
48. Doesnanythingnmakenyourndifficultynbreathingnbetternornworse?n
49. Doesnanythingnmakenyourncoughnbetternornworse?n
50. Donyounhavenanproblemnwithnfatigue?n
Step-by-stepnexplanation
ArielanHernandeznisnannAcutenonsetndyspneanandnsyncopeniHumanncasenstudynessaynMrs.
nArielanHernandeznisnan64nyearnoldnobesenfemalenwithnHTN,ncurrentnsmokernfornthenpastn40
nyears,ndiabetes,nrightnkneenreplacementnsurgeryn6nweeksnago,ncomplaintsnofnacutenonsetn
dyspneanandnnearnsyncopen.nShenisn5′n3″nandnweighsn200npounds.n
n
Askingnhernhistorynquestionsnwillnprovidenyounasnthenhealthcarenprofessionalnwithnannaccur
atenmedicalnhistorynandnhelpsnyoungetnanbetternunderstandingnofnAriela'snhealthnissues.nan
dnallowsnyountonidentifynpatternsnandnmakenmoreneffectivendecisionsnbasednonnAriela'snspe
cificnhealthnneeds.n
n
Ariela Hernandez Acute onset dysp n n n n
nea and syncope iHuman casestudy n n n n n n
(4 Different Versions) n n
Ariela Hernandez Acute onset dyspnea and syncope iHuman casestud
n n n n n n n n n
y essay n
64 years n n
5′ 3″ n n
200 pounds Ariel n n
a Hernandez
n
Chief complaint: n
Acute onset dyspnea and near syncope
n n n n n
Mrs. Hernandez is a 64 year old obese female with HTN, current smokerfor
n n n n n n n n n n n n n n
the past 40 years, diabetes, right knee replacement surgery 6 weeksago, c
n n n n n n n n n n n n
omplaints of acute onset dyspnea and near syncope started approximate
n n n n n n n n n
ly 3 hours ago. Associated symptoms SOB, cough, right calf slightly tend
n n n n n n n n n n n
er and swollen. Physical examination demonstrates signs of possible PE.
n n n n n n n n n
Trace to 1+ edema to ankles on left, 2+ edema to knee on right, well healin
n n n n n n n n n n n n n n n
g incisional scar overlying right knee from recent surgery slightlyswollen
n n n n n n n n n n n
compared to left right calf slightly tender, left calf non tender,no left join
n n n n n n n n n n n n n
t swelling or erythema, no clubbing or cyanosis, extremities are well perfu
n n n n n n n n n n n
sed Ariela Hernandez Acute onset dyspnea and syncopeiHuman case stud
n n n n n n n n n n
y essay.
n
Abdomen-
normal, no tenderness, no masses appreciated, liver ofnormal size, smoot
n n n n n n n n n n n
h edge palpable, spleen normal
n n n n
Note the three tabs: 1) current visit (blank EMR), 2) Pt. Info Forms (contains
n n n n n n n n n n n n n n
Vital Signs for current visit) and 3) 1 month ago (contains
n n n n n n n n n n
n
,n
records from outpatient surgical visit 1 month ago). These tabs providevital i
n n n n n n n n n n n n
nformation.
For this case there are 22 required history questions:(C
n n n n n n n n n
C (2), HPI/Symptom+ Assoc. Symptoms (10),
n n n n n
PMH/Surg/Hosp/Meds/Environment (4), Allergies (1), FH (0), SH (0),
n n n n n n n
Prevention/Risk Behaviors (0), ROS (5).
n n n n
History Questions n
ArielanHernandeznisnannAcutenonsetndyspneanandnsyncopeniHumanncasenstudynessaynThe
nhistorynquestionsntonasknArielanHernandeznare:n
1. Wherendonyounlive?n
2. Donyounhavenanynchildren,nspouse,nornpartner?n
3. Donyounsmoke?n
4. Hownmanynyearsnhavenyounbeennsmoking?n
5. Hownmuchndonyounsmokenanday?n
6. Donyounhavenanynhistorynofnlungndisease?n
7. Donyounhavenasthma?n
8. Donyounusenanynrecreationalndrugs?n
9. Tellnmenaboutnanyncurrentnornpastnmedicalnproblems.n
10. Arenyountakingnanynprescriptionnmedications?n
11. Arenyountakingnanynovernthencounternornherbalnmedications?n
12. Donyoundrinknalcohol?nIfnso,nwhatndonyoundrinknandnhownmanyndrinksnpernday?n
13. Donyountakeninsulinnforndiabetes?n
14. Donyoundrinkncaffeinatednbeveragesnorneatnchocolate?n
15. Tellnmenaboutnyourndiet,nwhatnyounnormallyneat?n
16. Donyounhavenanynproblemsnwith:nnervousness,ndepression,nlacknofninterest,nsadne
ss,nmemorynloss,nornmoodnchanges,nornevernhearnvoicesnthatnyounknownarennotnthe
re?n
17. Whennyounurinate,nhavenyounnoticed:npain,ndifficultynstartingnornstopping,ndribbling,ni
ncontinence,nurgencynduringndaynornnight.nAnynchangesninnfrequency?nAnynbloodninn
yournurine?n
18. Arenyouncoughingnupnanynsputum?n
19. Isntherenanynpatternntonyourncough?n
20. Whatntreatmentsnhavenyounhadnfornyourncough?n
21. Donyounhavenproblemsnwith:nnausea,nvomiting,nconstipation,ndiarrhea,ncoffeen
groundsninnyournvomit,ndarkntarrynstool,nbrightnrednbloodninnyournbowelnmovem
ents,nearlynsatiety,nbloating?n
22. Donyounhavenproblemsnwith:nmusclenornjointnpain,nredness,nswelling,nmusclencr
amps,njointnstiffness,njointnswellingnornredness,nbacknpain,nnecknornshouldernpa
in,nhipnpain?n
23. Havenyounevernbeennhospitalized?n
n
, n
24. hatnkindnofnworkndonyoundo?n
25. Donyounhavenanynallergies??n
26. Donyounhavenanynproblemsnwith:nheadachesnthatndon'tngonawaynwithnaspirinnorn
Tylenoln(acetaminophen),ndoublenornblurrednvision,ndifficultynwithnnightnvision,np
roblemsnhearing,nearnpain,nsinusnproblems,nchronicnsorenthroats,ndifficultynswall
owingn
27. Havenyounnoticed:nanynbruising,nbleedingngumsnornothernsitesnofnincreasedn
bleeding?n
28. Donyounhavenanynofnthenfollowing:nheatnorncoldnintolerance,nincreasednthirst,n
sweating,nfrequentnurination,nchangeninnappetite?n
29. Donyounhavenanynofnthenfollowing:ndizziness,nfainting,nspinningnroom,nseizures,n
weakness,nnumbness,ntingling,ntremor?n
30. Isntherenanpatternntonwhennyounhavendifficultynbreathing?n
31. Donyounhavenanynpainninnyournchest?n
32. Doesnyournchestnfeelntightnornheavy?n
33. Donyounhavenanynofnthenfollowingnproblems:nfatigue,ndifficultynsleeping,n
unintentionalnweightnlossnorngain,nfevers,nnightnsweats?n
34. Donyounhavenanynproblemsnwith:nitchynscalp,nskinnchanges,nmoles,nthinningnhair,n
brittlennails?n
35. Havenyounbeenninnansituationnwherenyounwerensittingnornlyingnstillnfornanlongntime?n
36. Arenyounshortnofnbreathnwhennlyingndown?n
37. Donyounawakennatnnightnshortnofnbreath?n
38. Donyounhavenunusualnheartbeatsn(palpitations)?n
39. Donyounsleepnwithnpillowsntonhelpnyounbreathe?n
40. Donyounfeelnasnifnyounarensmotheringnornsuffocating?n
41. Donyounwheeze?n
42. Anynpreviousnmedicalnsurgical,norndentalnprocedures?n
43. Havenyounevernhadnthisnillnessnbefore?n
44. Donyounhavenpainnanywhere,nifnsonwhere?n
45. Whatnisnthenmostndistressingnsymptomnfornyou?n
46. Hasnyournlevelnofnactivitynrecentlynchanged?n
47. Arenyouninngoodnspiritsnmostnofnthentime?n
48. Doesnanythingnmakenyourndifficultynbreathingnbetternornworse?n
49. Doesnanythingnmakenyourncoughnbetternornworse?n
50. Donyounhavenanproblemnwithnfatigue?n
Step-by-stepnexplanation
ArielanHernandeznisnannAcutenonsetndyspneanandnsyncopeniHumanncasenstudynessaynMrs.
nArielanHernandeznisnan64nyearnoldnobesenfemalenwithnHTN,ncurrentnsmokernfornthenpastn40
nyears,ndiabetes,nrightnkneenreplacementnsurgeryn6nweeksnago,ncomplaintsnofnacutenonsetn
dyspneanandnnearnsyncopen.nShenisn5′n3″nandnweighsn200npounds.n
n
Askingnhernhistorynquestionsnwillnprovidenyounasnthenhealthcarenprofessionalnwithnannaccur
atenmedicalnhistorynandnhelpsnyoungetnanbetternunderstandingnofnAriela'snhealthnissues.nan
dnallowsnyountonidentifynpatternsnandnmakenmoreneffectivendecisionsnbasednonnAriela'snspe
cificnhealthnneeds.n
n
