Exam (elaborations)
I HUMAN CASE STUDY FOR KAREN BARNES #3CC;49-YEAR-OLD FEMALE CARDIOVASCULAR
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I HUMAN CASE STUDY FOR KAREN BARNES #3CC;49-YEAR-OLD FEMALE CARDIOVASCULAR
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, Advanced Health AssessmentInstructions: 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
specificity and accuracy. Students are also expected to incorporate any feedback faculty have provided
on previous cases into each subsequent assignment.
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
Chief complaint is a short 1-2
statement or word phrase from patient
in the cold. She reports that the chest pain radiates to the
and should be listed in “quotes” left arm and has a squeezing quality to it. The pain is
exacerbated by fast walking in the cold and relieved by
“Exertional mid-chest pain that resting.
radiates to left arm with a
squeezing quality” Onset: Chest pain 2 week ago during a cross-country ski
run
HPI: pertinent s/s; +/- ROS/prior
episodes/recent travel/ill contacts
PMHx child/adult illness/hospitalizations/immunizations History of hypertension
and high cholesterol
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