iHuman Case Study: Ariela Hernandez – Acute Dyspnea and Near Syncope
Ariela Hernandez, a 64-year-old obese female with a history of hypertension, 40 years of smoking, diabetes, and recent right knee replacement surgery, presents with a chief complaint of acute dyspnea and near syncope for the past 3 hours. Associated symptoms include shortness of breath, cough, and slight tenderness and swelling in the right calf. Physical examination reveals signs suggestive of a possible pulmonary embolism (PE).
Notable findings include 1+ edema to the left ankle and 2+ edema to the right knee. The incisional scar overlying the recent right knee surgery appears slightly swollen compared to the left knee. There is tenderness and swelling in the right calf, while the left calf is non-tender. No joint swelling or erythema is observed, and no clubbing or cyanosis is present. The extremities are well-perfused.
Abdominal examination reveals normal findings with no tenderness, masses, or abnormalities in the liver and spleen.
As part of the case requirements, a comprehensive history must be obtained, and the patient’s current status should be assessed to determine the appropriate level of care. Additionally, any abnormal findings during the history and physical assessment must be documented in the problem list. The completion of the problem list exercise and a concise problem statement will contribute to the overall case play score.
Questions Asked: iHuman Case Study: Ariela Hernandez – Acute Dyspnea and Near Syncope
- What is your name?
- How old are you?
- Where are you currently?
- Where do you live?
- With whom are you living?
- Do you have any children, spouse, or significant partner?
- Do you practice any religion?
- Why are you seeking help today?
- Are there any other symptoms you’re experiencing?
- How many years have you been smoking?
- What is your daily smoking habit?
- Do you have any history of lung disease?
- Are you diagnosed with asthma?
- Do you use any recreational drugs?
- How would you describe your overall health?
- Tell me about any current or past medical problems.
- Are your immunizations up to date?
- Are you taking any prescription medications?
- Do you take any over-the-counter or herbal medications?
- Do you drink alcohol, and if so, what and how much per day?
- Do you take insulin for diabetes?
- Has anyone suggested reducing your alcohol intake?
- Do you consume caffeinated beverages or eat chocolate?
- Describe your typical diet.
- Do you experience nervousness, depression, lack of interest, sadness, memory loss, mood changes, or auditory hallucinations?
- Any issues during urination, such as pain, difficulty starting or stopping, dribbling, incontinence, urgency, or changes in frequency or blood in urine?
- Are you coughing up any sputum?
- Any pattern to your cough, and what treatments have you tried?
- Issues with nausea, vomiting, constipation, diarrhea, coffee-ground vomit, dark tarry stool, bright red blood in bowel movements, early satiety, or bloating?
- Problems with muscle or joint pain, swelling, cramps, stiffness, or back, neck, shoulder, or hip pain?
- Have you ever been hospitalized?
- Tell me about your work.
- Do you have any allergies?
- Any headaches that persist with pain relievers, double or blurred vision, difficulty with night vision, hearing problems, ear pain, sinus issues, sore throats, or difficulty swallowing?
- Notice any bruising, bleeding gums, or increased bleeding?
- Experience heat or cold intolerance, increased thirst, sweating, frequent urination, or changes in appetite?
- Any dizziness, fainting, spinning sensations, seizures, weakness, numbness, tingling, or tremors?
- Is there a specific pattern to when you have difficulty breathing?
- Any chest pain or tightness?
- Do you have symptoms of fatigue, difficulty sleeping, unintentional weight changes, fevers, or night sweats?
- Issues with itchy scalp, skin changes, moles, thinning hair, or brittle nails?
- Have you been immobile for an extended period?
- Do you experience shortness of breath when lying down?
- Wake up at night short of breath?
- Notice unusual heartbeats (palpitations)?
- Use extra pillows to aid breathing while sleeping?
- Feel as if you are smothering or suffocating?
- Do you wheeze?
- Any previous medical, surgical, or dental procedures?
- Have you had this illness before?
- Do you currently experience pain, and if so, where?
- What is the most distressing symptom for you?
- Has your level of activity changed recently?
- Are you generally in good spirits?
- Does anything alleviate or worsen your difficulty breathing?
- Does anything improve or worsen your cough?
- Do you struggle with fatigue?
Reviewed FSG home glucose monitoring results. Still running a bit high. Encouraged the patient to schedule a visit with PCP.
Subjective (S): Mrs. Hernandez, a 64-year-old woman, here for a routine follow-up 2 weeks post-right knee replacement, expresses difficulty with physical therapy and residual pain. She continues to smoke against recommendations.
Objective (O): Vital signs are normal, surgical scar healing well without signs of infection. Lungs are clear, heart sounds regular, abdomen soft and non-tender, neurological reflexes intact, and the right knee shows healing progress.
Assessment (A): Normal recovery for a right-knee replacement in an obese type 2 diabetic patient who continues to smoke.
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