64 years 5' 3" 200 pounds Ariela Hernandez Chief complaint: Acute onset dyspnea and near syncope Mrs. Hernandez is a 64 year old obese female with HTN, current smoker for the past 40 years, diabetes, right knee replacement surgery 6 weeks ago, complaints of acute onset dyspnea and near syncope started approximately 3 hours ago. Associated symptoms SOB, cough, right calf slightly tender and swollen. Physical examination demonstrates signs of possible PE. Trace to 1+ edema to ankles on left, 2+ edema to knee on right, well healing incisional scar overlying right knee from recent surgery slightly swollen compared to left right calf slightly tender, left calf non tender, no left joint swelling or erythema, no clubbing or cyanosis, extremities are well perfused Abdomen- normal, no tenderness, no masses appreciated, liver of normal size, smooth edge palpable, spleen normal
At the start of the case click on “Show Patient Record, above the Problem List Icon . Note the three tabs: 1) current visit (blank EMR), 2) Pt. Info Forms (contains Vital Signs for current visit) and 3) 1 month ago (contains records from outpatient surgical visit 1 month ago). These tabs provide vital information. You must receive an overall score greater than or equal to 80% to have mastered this course. For this case there are 22 required history questions: (CC (2), HPI/Symptom+ Assoc. Symptoms (10), PMH/Surg/Hosp/Meds/Environment (4), Allergies (1), FH (0), SH (0), Prevention/Risk Behaviors (0), ROS (5). 1. Take the patient's HISTORY . Decide of this is a patient that can be treated as an outpatient; focused case – fewer history questions needed versus a patient who might be hospitalized for treatment (comprehensive case) where all components of a history.
You've reached the end of your free preview.
Want to read all 7 pages?