IHUMAN Case Study
Perpetual Anita Aseme
IHUMAN CASE # 3: Cardiovascular Karen Barnes
NURS5342
, Case: 165484 Karen Barnes Date:
03/06/2021
Advanced Health Assessment
March 6, 2021
Instructions: Type patient encounter information directly into each box of the template. Students should avoid the use of the following terms:
“WNL”/”Normal”, etc and should document systems with sp ecificity and accuracy. Students are also expected to incorporate any feedback faculty
have provided on previous cases into each subsequent assign ment.
CC: 49-year-old female Ms. Barnes is a 49-year-old female with chest pain and dyspnea that started 2
weeks ago during a ski run activity in the cold. She reports that the chest pain
Chief complaint is a short 1-2 statement or word phrase
radiates to the left arm and has a squeezing quality to it. The pain is
from patient and should be listed in “quotes”
exacerbated by fast walking in the cold and relieved by resting.
“Exertional mid-chest pain that radiates to Onset: Chest pain 2 week ago during a cross-country ski run
left arm with a squeezing quality”
HPI: pertinent s/s; +/- ROS/prior episodes/recent
travel/ill contacts
PMHx child/adult Duration: The chest pain comes and goes. Lasts several minutes and occurs1-2
History of
illness/hospitalizations/immunizations times a week
hypertension and high cholesterol Character: Chest pain with a squeezy quality and radiates to the left arm. Pain
Missed this year’s flu vaccination scale of 5 or 6 on scale of 1-10
Location: Mid chest that radiates to left Aggravating/alleviating factors: Precipitated by exercise and improves with
arm rest
Related symptoms: Dyspnea that occurs with chest pain with exertion
Perpetual Anita Aseme
IHUMAN CASE # 3: Cardiovascular Karen Barnes
NURS5342
, Case: 165484 Karen Barnes Date:
03/06/2021
Advanced Health Assessment
March 6, 2021
Instructions: Type patient encounter information directly into each box of the template. Students should avoid the use of the following terms:
“WNL”/”Normal”, etc and should document systems with sp ecificity and accuracy. Students are also expected to incorporate any feedback faculty
have provided on previous cases into each subsequent assign ment.
CC: 49-year-old female Ms. Barnes is a 49-year-old female with chest pain and dyspnea that started 2
weeks ago during a ski run activity in the cold. She reports that the chest pain
Chief complaint is a short 1-2 statement or word phrase
radiates to the left arm and has a squeezing quality to it. The pain is
from patient and should be listed in “quotes”
exacerbated by fast walking in the cold and relieved by resting.
“Exertional mid-chest pain that radiates to Onset: Chest pain 2 week ago during a cross-country ski run
left arm with a squeezing quality”
HPI: pertinent s/s; +/- ROS/prior episodes/recent
travel/ill contacts
PMHx child/adult Duration: The chest pain comes and goes. Lasts several minutes and occurs1-2
History of
illness/hospitalizations/immunizations times a week
hypertension and high cholesterol Character: Chest pain with a squeezy quality and radiates to the left arm. Pain
Missed this year’s flu vaccination scale of 5 or 6 on scale of 1-10
Location: Mid chest that radiates to left Aggravating/alleviating factors: Precipitated by exercise and improves with
arm rest
Related symptoms: Dyspnea that occurs with chest pain with exertion
