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IHUMAN Case Week #10, A 50-Year-Old Female Reason for Encounter-Fatigue and Shortness of Breath Case Study 2024
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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
that seems to help. They are worse with any exertion. How long does your headache last? A couple hours until the ibuprofen kicks in When did your headache start? Over the last few months. I don’t have one now. Do you have any awareness or warning symptoms that occur before the headache begins? No What treatments have you had for your headache? I just take some ibuprofen when I get one Does your headache come and go? Yes,. I don’t have one right now. How severe (1-10) is your headache? I’d say mild Where more precisely is the pain in your head? Kind of all over. Just garden variety headache. Does the pain in your head radiate someplace else? Where? I don’t have a headache now but when I have one, it stays in one place. How long do your periods last? I have heavy bleeding for 2-3 days, but the total duration is usually around 7-8 days. How many tampons or pads do you use daily? I use both simultaneously; I double up using both tampons and pads for the 昀 椀 rst 2-3 days and I change my tampon every two to four hours. Now that I think about it, it is heavier than it was a couple of years ago. When did your last period begin? About 4 weeks ago When did your abnormal vaginal bleeding start? It’s been a little heavier for about 10 months or a year Do you have any pain in your chest? No Any changes in the frequency of your bowel movements? I have loose stools occasionally and have been having them over the past year or so. Otherwise, nothing new. How often do you have headaches like this? iHuman does not have this question anymore How often do you feel lightheaded? iHuman does not have this question anymore How much of your medication did you take? Do you have problems with heat or cold intolerance, increased thirst, increased sweating, frequent urination, or change in appetitie? iHuman does not have this question anymore, so I broke it up to get the answers I needed. See the next four questions. Do you have trouble with hot or cold temperatures? No, I don’t think so. Any changes in your thirst? No increased thirst, urination or appetite. All good. How is your appetite? Any recent change? Oh, my appetite is 昀椀 ne. Always is. Has there been a change in your urination frequency? No Do you have night sweats? No Do you bruise or bleed easily? Nope Tell me about your work? I’m a radiology tech. I work in private practice Do you now or have you ever smoked or chewed tobacco? Never Are your immunizations up to date? Yes, they are Have you ever had a Pap smear? Yes. I stay on top of that and they are always normal. Over the last two weeks, how often have you been bothered by feeling down, depressed, or hopeless? Don’t have that problem
Have you ever been hospitalized? Just for the deliveries of my kids Is there any blood in your stools or with your bowel movements? Nope. Do you have pain/discomfort when you urinate? Nope Have you been having fevers? No Do you have chills? No Do you have any skin itching or burning? No Do you have any skin problems? iHuman does not have this question anymore Do you have any breast issues? iHuman does not have this question anymore Do you have joint or bone pain? Nope Do you have any nausea or vomiting? No Do you have unusual heartbeats (palpitations)? No, I haven’t
Inspect skin overall: Slight pallor. No jaundice, petechiae, ecchymoses, Inspect hair color, distribution, thickness: 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: Cap
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 Palpate sinuse : Inspect eyes: (^) : PERRLA Examine pupils Perform ocular motor test: Normal eye movement. Perform fundoscopic exam with ophthalmoscope: 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. Inspect nose external/internal:^ Nose is free of discharge or polyps. Inspect mouth/pharyn (^) 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: Auscultate heart: Measure JV 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.
Palpate breast tissue : No masses or tenderness bilaterally at four quadrants and tails. Symmetric Measure thoracic expansion: 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. Percuss/palpate spleen : Spleen not palpable Auscultate abdominal/femoral arteries: 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: Palpate cervical lymph nodes: Palpate axillary lymph nodes: Palpate inguinal lymph nodes 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
