I HUMAN CASE 50 YEAR OLD FEMALE REASON FOR ENCOUNTER: FATIGUE AND SHORTNESS OF BREATH 6512, Exams of Nursing

Download I HUMAN CASE 50 YEAR OLD FEMALE REASON FOR ENCOUNTER: FATIGUE AND SHORTNESS OF BREATH 6512 and more Exams Nursing in PDF only on Docsity! I HUMAN CASE WEEK #10 A 50 YEAR OLD FEMALE REASON FOR ENCOUNTER: FATIGUE AND SHORTNESS OF BREATH CASE STUDY 2024 50 y/o female Height: 5’6” (168 cm) Weight: 153 lbs (69.5 kg) Reason for visit: Fatigue and shortness of breath Location: Emergency room with full imaging and laboratory capabilities Visual: Alert, slight pallor, dress in gown Note: There is a prior chart in the EHR HISTORY QUESTIONS: 24 cd CC Sx How can | help you today? Is your urine pink or red in color @ Assoc SX (biood in urine)? @ = Assoc Sx D2 you have pain/discomfort when you urinate? oO ‘Assoc Sk Any change in the frequency of your bowel movements? Do you have any pain in your @ = Assoc Sx leg(s)? Do you have any pain in your e ASSOC abdomen? e Assoc Sx | Have you been having fevers? | have this pain down in my private parts on the left. My dad's here, but he said he had to move the car because it was parked in a bad place. He wants me to answer all the questions, if | can No. | can't see any. No, that's not where the pain is. No, | don't think so. | went last night. No, it's down low... in my groin...that's what my dad calls it.. and my privates -- on the left. It's not in my stomach. It's, down here low on the left. My dad keeps calling it my "groin". It really hurts. No. It doesn't feel like it. * Tespiration Tespiration ured, « temperature @ temperature @ Performed Con * Spo: @ Spo: ® Not Required, ¢ visual inspection abdomen | @ visual inspection abdomen @ | @ Performed Cor ¢ auscultate abdomen @ auscultate abdomen @ Performed Cor * palpate abdomen | @ palpate abdomen ® | @ Performed Cort * percuss abdomen @ percuss abdomen @® @ Performed Cor * genitourinary male exam | @ genitourinary male exam @ @ Performed Cor * palpate all lymph nodes @ palpate all lymph nodes @ @ Performed Cor |_* auscultate heart | @ auscultate heart | @ Performed Con PHM,FH,SH Questions Can you tell me about any current or past medical problems you have had? I have been lucky and very healthy. No heart disease, blood problems, or anything else like that. Are you taking any prescription medications? None at all Are you taking any OTC or herbal medications? Occasionally I take ibuprofen if I get a cold and have a fever but that hasn’t been my problem recently. My headaches are the reason that I’ve been taking ibuprofen now. Are you now or have you ever been anemic? iHuman does not have this question anymore Do you have allergies? Not that I’m aware of Can you tell me about your diet? What do you normally eat? I turned vegan about 2 years ago. I think it will help me keep my weight under control. Do you drink alcohol? If so, what do you drink and how many drinks per day? I drink a glass of wine with dinner pretty much every day. HPI Statement AP is a 50 y/o female who presents with several months of fatigue and lightheadedness, shortness of breath, and headaches. Shortness of breath has been going on for several months. Worse with activity and better with rest. Fatigue for several months impacting her quality of life. Better with rest. Worse with activity. Denies resolution after a good night's rest. She reports dizziness when changing positions. Syncope this morning with activity. Headaches that come and go. Aching and Mild in nature. Worse with activity. Better after taking Ibuprofen. In addition, she reports heavy menstrual periods for a year. LMP 4 weeks ago, lasting 7-8 days with 2-3 of heavy bleeding and having to change her tampon and pad every 2-4 hours. She reports taking OTC Ibuprofen for her headaches. Denies di昀케culty swallowing, pain radiating elsewhere, or chest pain. PHYSICAL EXAMS: 25 Cognitive status: A&O x 4 Vital Signs: Looked in chart for credit BP: Left: 126/72, right: 128/74, assessment: normotensive, pulse pressure: normal Orthostatic BP 104/60, upon standing Pulse: 82 bpm, rhythm: regular, strength: normal Resp: 16 bpm, rhythm: regular, e昀昀ort: unlabored SPo2: 97%, RA Temp: 98.6 F (37 c), oral Height: 66” Weight: 153 lb BMI: 24.7 SKIN: Slight pallor. No jaundice, petechiae, ecchymoses, rashes, or lesions. Thickness and distribution pattern typical for patient gender and age. Test skin turgor: Back of hand-skin snaps back rapidly Test cap re昀椀ll-昀椀ngers: Capillary re昀椀ll less than three seconds Test capillary re昀椀ll-toes: Capillary re昀椀ll less than three seconds bilaterally Inspect nails: Nails without ridging, pitting, or peeling. HEENT/NECK Inspect/palpate head (including scalp): Normocephalic, atraumatic. No deformities. Facial features symmetric. Temporal arteries non-tender to palpation Maxillary and frontal sinuses non- tender on both sides. No scleral icterus. Mild conjunctival pallor. No periorbital edema. Red re昀氀ex bilaterally. Optic disks sharp. Test visual acuity: Visual acuity with Snellen pocket cared: right eye (OD) 20/20, left eye (OS) 20/20. Inspect external ears: No cauli昀氀ower deformation, lesions, masses, or erythema to external ears. Look in ears with otoscope: External auditory canals without erythema or cerumen. Tympanic membrane translucent, non-injected, and pinkish-gray in color. No scarring, discharge or purulence noted. Landmarks visible. Nose is free of discharge or polyps. Lips dry. Mild 昀椀ssures bilateral angles of the mouth, slightly erythematous. No mucosal lesions. Inspect neck: No visible scars, deformities, or other lesions. Trachea is midline and freely mobile. Palpate neck: Palpate thyroid: Thyroid mobile without masses, tenderness, nodules, or enlargement. Evaluate cervical spine range of motion (non-meningeal): Full and painless active range of motion in 昀氀exion, extension, lateral bending, and rotation bilaterally. CARDIO: S1 and S2 regular rate and rhythm. No rubs, clicks or gallops No JVD Palpate for PMI: PMI in 5th intercostal space at midclavicular line. Single, brisk impulse. Auscultate carotid arteries: No bruits bilaterally Chest/Respiratory: Visual inspection-anterior & posterior chest (including breasts): No lifts or accessory muscle use. No scars, moles, rashes, erythema, or ecchymosis Palpate anterior & posterior chest: No tenderness, masses, heaves, thrills, or crepitus on palpation. Percuss anterior & Posterior chest: Anterior lung 昀椀elds are resonant. The left anterior chest (heart) and right lower chest (liver) are dull to percussion. The rest fo the lung 昀椀elds are resonant and are not hyper-resonant. Auscultate lungs: Bilateral lung sounds are clear anterior and posterior. No adventurous breath sounds noted. Inspect breast: No masses, erythema, rashes, discharge, dimpling, or retraction upon inspection with patient seated, arms raised, hands on hips, or supine. Inspect skin overall: Inspect hair color, distribution, thickness: Palpate sinuse s: : PERRLA Inspect eyes: Examine pupils Perform ocular motor test: Normal eye movement. Perform fundoscopic exam with ophthalmoscope: Inspect nose external/internal: Inspect mouth/pharyn x: Auscultate heart: Measure JV P: No masses or tenderness bilaterally at four quadrants and tails. Symmetric expansion bilaterally Abdomen Inspect abdomen: Nondistended. Scar consistent with appendectomy. No moles, masses, rashes, erythema, or ecchymosis. Auscultate abdomen: Bowel sounds normoactive and present in all four quadrants. Percuss abdomen/Palpate abdomen: iHuman no longer has these exams Perform initial light/deep abdominal palpation +/- percussion (4 quards): No tenderness or masses palpable upon light or deep palpation. Percuss/palpate liver: Liver is 8 cm at the midclavicular line, edge palpable just below costal margin. Spleen not palpable No bruits noted to renal, femoral or aortic arteries. Genitourinary/Rectal: Inspect rectal area: No visible 昀椀ssures, induration, or lesions Rectal exam: Genitourinary exam: Inspect vulva and urethral meatus: Mons with expected hair growth without excoriation, erythema, or rash. Labia majora and minora without erythema, masses, tenderness, or discharge. Meatus without discharge. Perform vaginal speculum examination: Vaginal walls pink without lesions, discharge, dryness, or erythema. Cervical os without erythema, bleeding, or discharge. Perform bimanual pelvic exam: No uterine masses or tenderness. Ovaries not palpable at adnexae. No adnexal tenderness or masses. Musculoskeletal/Osteopathic: Inspect upper extremities: Arms without rashes, lesions, moles, erythema, swelling or ecchymosis. No fasciculations or loss of muscle bulk. Inspect lower extremities: No swelling, pallor, hair loss, erythema, rashes, ulcerations, lesions, or ecchymosis bilaterally. Neurologic (A&O x 4) Assess cranial nerves Assess biceps re昀氀exes (DTR): 2+ bilaterally Assess triceps re昀氀exes (DTR): 2+ bilaterally Assess brachioradialis re昀氀exes (DTR): 2+ bilaterally Assess patellar re昀氀exes (DTR): 2+ bilaterally Assess achilles re昀氀exes (DTR): 2+ bilaterally Assess plantar/Babinski (L5-S1): 2+ bilaterally Assess stance & Gait: Upright posture and steady gait Psychiatric: Pleasant, calm and cooperative with exams. Answers questions appropriately Lymphatic: Nodes mobile, non-tender, pea-sized, and soft bilaterally. Nodes mobile, non-tender, pea-sized, and soft bilaterally. : Nodes mobile, non-tender, pea-sized, and soft bilaterally Palpate breast tissue : Measure thoracic expansion: Percuss/palpate spleen : Auscultate abdominal/femoral arteries: Palpate cervical lymph nodes: Palpate axillary lymph nodes: Palpate inguinal lymph nodes