Tina Jones Cardiovascular Results
Tina Jones Cardiovascular Results
Experience Overview
Patient: Tina Jones
Digital Clinical Experience Score
89.7%
This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 86.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent.
Student Performance Index
| 42.17
out of 47 |
Proficiency Level:
Developing
Students rated as “developing” demonstrate increasing clinical reasoning abilities as they apply their knowledge of advanced practice competencies. In comparable programs, 25% of students perform at the level of a developing practitioner. Review your results in the tabs on the left side of the page to identify areas for improvement.
Subjective Data Collection
19
out of
19
Objective Data Collection
22.17
out of
23
Education and Empathy
1
out of
5
Time
| 59 minutes total spent in assignment |
Interaction with patient
57 minutes
Post-exam activities
2 minutes
Transcript
Started: Apr 11, 2025 | Total Time: 57 min
All Lines (140)Interview Questions (44)Statements (4)Exam Actions (92)
| Inspected anterior chest wall | Exam Action 04/11/25 6:57 AM EDT |
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| Inspected left side chest wall | Exam Action 04/11/25 6:57 AM EDT |
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| Hi, my name is Mileidy | Greet 04/11/25 7:17 AM EDT |
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| Hey. | ||
| I will be your nurse today | Question 04/11/25 7:17 AM EDT |
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| Hello. | ||
| What brings you here today? | Question 04/11/25 7:18 AM EDT |
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| I’ve been noticing my heart seems to be beating too fast every once in a while lately, and it started to worry me. My mom said I should make an appointment. You don’t want to ignore heart stuff, I guess. | ||
| I am sorry for that | Empathize 04/11/25 7:18 AM EDT |
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| I appreciate you telling me that. | ||
| When did your heart condition start? | Question 04/11/25 7:18 AM EDT |
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| I think the first time was about a month ago. | ||
| What are your symptoms? | Question 04/11/25 7:19 AM EDT |
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| Well, aside from these palpitations, I’ve felt really low energy lately. I feel pretty exhausted by the end of the day. [AUDIO COMING SOON] | ||
| WHich symptoms do you have? | Question 04/11/25 7:19 AM EDT |
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| Well, aside from these palpitations, I’ve felt really low energy lately. I feel pretty exhausted by the end of the day. [AUDIO COMING SOON] | ||
| Do you take any medication? | Question 04/11/25 7:20 AM EDT |
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| I have a daily inhaler and a rescue inhaler for my asthma. | ||
| Do you have any allergies? | Question 04/11/25 7:20 AM EDT |
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| Yeah, I’m allergic to cats and dust. | ||
| Do you have any stress? | Question 04/11/25 7:20 AM EDT |
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| Yeah, I’ve been pretty stressed lately. | ||
| Do you have a history of heart conditions in your family? (Clarified to Does heart disease run in your family?.) | Question 04/11/25 7:21 AM EDT |
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| Um, none that I know of. Wait, my Poppa–that’s Mom’s dad–died of a heart attack. (Clarified to if I have a family history of heart problems.) | ||
| How is your diet? | Question 04/11/25 7:21 AM EDT |
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| It’s pretty good, I think. I’m not a huge health nut or anything. | ||
| How are your heartbeats? (Clarified to What is your heartbeat like?.) | Question 04/11/25 7:24 AM EDT |
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| It’s usually normal, but it’s way faster during these episodes I’ve been having. (Clarified to what my heartbeat is like.) | ||
| Do you have high blood pressure? | Question 04/11/25 7:25 AM EDT |
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| …I’ve never been diagnosed with blood pressure problems. But I think it can be on the high side sometimes. | ||
| Do you have heart murmurs? | Question 04/11/25 7:26 AM EDT |
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| No. | ||
| Do you have any swelling? | Question 04/11/25 7:26 AM EDT |
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| No, not that I have noticed. | ||
| Do you have blue skin? | Question 04/11/25 7:26 AM EDT |
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| Nope. | ||
| Have you had any cardiac tests? (Clarified to Have you had other heart tests?.) | Question 04/11/25 7:27 AM EDT |
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| Nope. (Clarified to if I have had other heart tests.) | ||
| Have you had any cardiac surgeries? | Question 04/11/25 7:27 AM EDT |
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| Nope. No surgeries… I’ve been lucky. | ||
| Do you have chest pain? | Question 04/11/25 7:28 AM EDT |
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| No, I’ve never had any chest pain. It doesn’t hurt, it just feels like my heart is beating really fast. | ||
| Do you have chest tightness? | Question 04/11/25 7:28 AM EDT |
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| Not really. | ||
| Do you have breathing problems? | Question 04/11/25 7:28 AM EDT |
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| No, my breathing is fine right now. | ||
| Do you drink alcohol? | Question 04/11/25 7:58 AM EDT |
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| I do sometimes, yeah, when I go out with my friends. | ||
| Do you smoke? | Question 04/11/25 7:59 AM EDT |
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| No. I think it’s gross. | ||
| Do you drink coffee? | Question 04/11/25 7:59 AM EDT |
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| Never. I don’t like it. Too bitter for my taste. I drink energy drinks instead. | ||
| How many energy drinks do you drink per day? | Question 04/11/25 7:59 AM EDT |
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| Usually just one in the morning, kind of like some people have a cup of coffee. Some mornings lately I’ve had two, though. | ||
| Do you use drugs? | Question 04/11/25 7:59 AM EDT |
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| No. | ||
| Which medication do you use? (Clarified to What medications do you take?.) | Question 04/11/25 8:00 AM EDT |
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| I have a daily inhaler and a rescue inhaler for my asthma. (Clarified to what medications I am taking.) | ||
| What were you doing when you got the palpitations? | Question 04/11/25 8:02 AM EDT |
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| I usually notice them on my way to class in the mornings. My schoolwork has really been picking up and I’ve been drinking energy drinks to help keep me focused during the day, so maybe the caffeine or whatever else is in those things has something to do with it. | ||
| Where if the location of the palpitations? | Question 04/11/25 8:03 AM EDT |
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| Well, it must be my heart…so, the left side of my chest. Left-center, I guess. | ||
| Drinking high levels of caffeine can make you feel stressed and anxious. | Educate 04/11/25 8:04 AM EDT |
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| Alright, thanks for letting me know. | ||
| How often do you experience these symptoms? (Clarified to How frequently do you experience difficulty breathing?.) | Question 04/11/25 8:04 AM EDT |
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| Not too often. I really haven’t had issues since I started my new daily inhaler about a month ago. (Clarified to how often I have trouble breathing.) | ||
| How often were you experiencing these symptoms? (Clarified to Have you had these symptoms before?.) | Question 04/11/25 8:04 AM EDT |
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| No. (Clarified to if I have had these symptoms before.) | ||
| How often do you have the symptoms? (Clarified to What are your PMS symptoms?.) | Question 04/11/25 8:05 AM EDT |
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| I get bad cramps, and I get grumpy for a couple days. (Clarified to what my PMS symptoms are.) | ||
| What makes the palpitations better? | Question 04/11/25 8:05 AM EDT |
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| I try to slow down and breathe, and just relax. The feeling usually goes away after awhile. | ||
| How do you fell when your heart is racing fast? (Clarified to What do you do when your heart races?.) | Question 04/11/25 8:06 AM EDT |
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| I try to slow down and breathe, and just relax. The feeling usually goes away after awhile. (Clarified to what I do when my heart races.) | ||
| Do you take any medications? | Question 04/11/25 8:06 AM EDT |
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| I have a daily inhaler and a rescue inhaler for my asthma. | ||
| What medications are you taking? | Question 04/11/25 8:07 AM EDT |
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| I have a daily inhaler and a rescue inhaler for my asthma. | ||
| Do you have a history of hypertension | Question 04/11/25 8:07 AM EDT |
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| …I’ve never been diagnosed with blood pressure problems. But I think it can be on the high side sometimes. | ||
| Do you check your blood pressure? | Question 04/11/25 8:07 AM EDT |
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| Only when I’m here at the clinic. | ||
| Do you have diabetes? | Question 04/11/25 8:07 AM EDT |
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| Yeah, I was diagnosed a few years ago. | ||
| Do you have any stress? | Question 04/11/25 8:08 AM EDT |
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| Yeah, I’ve been pretty stressed lately. | ||
| Do you exercise? | Question 04/11/25 8:08 AM EDT |
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| I’m pretty exhausted by the end of the day, so I don’t have the energy to do any extra exercise. But I’m on my feet all the time at work so I feel like that’s a little bit of exercise most days at least. | ||
| Do you drink alcohol? | Question 04/11/25 8:08 AM EDT |
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| I do sometimes, yeah, when I go out with my friends. | ||
| When do the palpitations occur? | Question 04/11/25 8:13 AM EDT |
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| I’ve only noticed them in the mornings, usually on the way to class. Maybe like once a week. | ||
| How does your heart feel during the palpitations? | Question 04/11/25 8:14 AM EDT |
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| Well, my heart doesn’t hurt, but it feels like thumping. Just a fast, thumping heartbeat, I guess. | ||
| What is the name of your daily inhaler? | Question 04/11/25 8:15 AM EDT |
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| The daily inhaler is Flovent, and the rescue inhaler is Proventil. | ||
| Exercise is health for your body and can help relief stress | Educate 04/11/25 8:15 AM EDT |
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| Alright, thanks for letting me know. | ||
| A family history of hypertension means that you may be at risk of developing it and its therefore important to monitor it. | Educate 04/11/25 8:16 AM EDT |
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| OK, I understand. | ||
| Inspected anterior chest wall | Exam Action 04/11/25 8:18 AM EDT |
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| Inspected left side chest wall | Exam Action 04/11/25 8:18 AM EDT |
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| Inspected posterior chest wall | Exam Action 04/11/25 8:18 AM EDT |
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| Inspected left side chest wall | Exam Action 04/11/25 8:18 AM EDT |
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| Inspected anterior chest wall | Exam Action 04/11/25 8:18 AM EDT |
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| Inspected right side chest wall | Exam Action 04/11/25 8:18 AM EDT |
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| Inspected anterior chest wall | Exam Action 04/11/25 8:18 AM EDT |
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| Inspected for jugular venous distention: JVP 1 cm above sternal angle | Exam Action 04/11/25 8:18 AM EDT |
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| Inspected fingernails of right hand | Exam Action 04/11/25 8:19 AM EDT |
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| Inspected fingernails of left hand | Exam Action 04/11/25 8:19 AM EDT |
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| Checked capillary refill in fingernails | Exam Action 04/11/25 8:19 AM EDT |
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| Checked capillary refill in fingernails | Exam Action 04/11/25 8:19 AM EDT |
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| Checked capillary refill in fingernails | Exam Action 04/11/25 8:19 AM EDT |
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| Checked capillary refill in fingernails | Exam Action 04/11/25 8:19 AM EDT |
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| Checked capillary refill in fingernails | Exam Action 04/11/25 8:19 AM EDT |
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| Checked capillary refill in fingernails | Exam Action 04/11/25 8:19 AM EDT |
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| Checked capillary refill in fingernails | Exam Action 04/11/25 8:20 AM EDT |
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| Checked capillary refill in fingernails | Exam Action 04/11/25 8:20 AM EDT |
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| Inspected legs | Exam Action 04/11/25 8:20 AM EDT |
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| Inspected right leg for edema: No edema | Exam Action 04/11/25 8:20 AM EDT |
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| Inspected left leg for edema: No edema | Exam Action 04/11/25 8:20 AM EDT |
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| Inspected right leg | Exam Action 04/11/25 8:20 AM EDT |
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| Inspected legs | Exam Action 04/11/25 8:20 AM EDT |
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| Inspected left leg | Exam Action 04/11/25 8:20 AM EDT |
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| Inspected legs | Exam Action 04/11/25 8:20 AM EDT |
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| Inspected toenails | Exam Action 04/11/25 8:20 AM EDT |
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| Checked capillary refill in toenails | Exam Action 04/11/25 8:20 AM EDT |
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| Checked capillary refill in toenails | Exam Action 04/11/25 8:20 AM EDT |
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| Checked capillary refill in toenails | Exam Action 04/11/25 8:20 AM EDT |
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| Checked capillary refill in toenails | Exam Action 04/11/25 8:21 AM EDT |
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| Checked capillary refill in toenails | Exam Action 04/11/25 8:21 AM EDT |
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| Checked capillary refill in toenails | Exam Action 04/11/25 8:21 AM EDT |
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| Checked capillary refill in toenails | Exam Action 04/11/25 8:21 AM EDT |
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| Checked capillary refill in toenails | Exam Action 04/11/25 8:21 AM EDT |
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| Checked capillary refill in toenails | Exam Action 04/11/25 8:21 AM EDT |
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| Checked capillary refill in toenails | Exam Action 04/11/25 8:21 AM EDT |
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| Inspected legs | Exam Action 04/11/25 8:21 AM EDT |
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| Palpated temporal arteries: No thrill on either side, 2+ on both sides | Exam Action 04/11/25 8:22 AM EDT |
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| Palpated right carotid pulse: No thrill, 2+ | Exam Action 04/11/25 8:22 AM EDT |
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| Palpated left carotid pulse: No thrill, 2+ | Exam Action 04/11/25 8:22 AM EDT |
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| Palpated chest at PMI: Present at midclavicular line and 5th intercostal space, brisk and tapping, diameter 2 cm | Exam Action 04/11/25 8:22 AM EDT |
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| Palpated right radial pulse: No thrill, 2+ | Exam Action 04/11/25 8:23 AM EDT |
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| Palpated left radial pulse: No thrill, 2+ | Exam Action 04/11/25 8:23 AM EDT |
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| Palpated right brachial pulse: No thrill, 2+ | Exam Action 04/11/25 8:23 AM EDT |
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| Palpated left brachial pulse: No thrill, 2+ | Exam Action 04/11/25 8:23 AM EDT |
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| Palpated right femoral pulse: No thrill, 2+ | Exam Action 04/11/25 8:23 AM EDT |
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| Palpated left femoral pulse: No thrill, 2+ | Exam Action 04/11/25 8:23 AM EDT |
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| Palpated right popliteal pulse: No thrill, 2+ | Exam Action 04/11/25 8:24 AM EDT |
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| Palpated left popliteal pulse: No thrill, 2+ | Exam Action 04/11/25 8:24 AM EDT |
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| Palpated right tibial pulse: No thrill, 2+ | Exam Action 04/11/25 8:24 AM EDT |
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| Palpated left tibial pulse: No thrill, 2+ | Exam Action 04/11/25 8:24 AM EDT |
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| Palpated right dorsalis pedis pulse: No thrill, 2+ | Exam Action 04/11/25 8:24 AM EDT |
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| Palpated left dorsalis pedis pulse: No thrill, 2+ | Exam Action 04/11/25 8:25 AM EDT |
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| Auscultated left temporal pulse | Exam Action 04/11/25 8:25 AM EDT |
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| Auscultated right temporal pulse | Exam Action 04/11/25 8:25 AM EDT |
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| Auscultated right carotid pulse | Exam Action 04/11/25 8:25 AM EDT |
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| Auscultated left carotid pulse | Exam Action 04/11/25 8:25 AM EDT |
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| Auscultated breath sounds in anterior right upper lobe | Exam Action 04/11/25 8:25 AM EDT |
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| Auscultated breath sounds in anterior left upper lobe | Exam Action 04/11/25 8:26 AM EDT |
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| Auscultated breath sounds in anterior right middle lobe | Exam Action 04/11/25 8:26 AM EDT |
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| Auscultated breath sounds in anterior left mid-chest (upper lobe) | Exam Action 04/11/25 8:26 AM EDT |
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| Auscultated breath sounds in anterior right lower lobe | Exam Action 04/11/25 8:26 AM EDT |
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| Auscultated breath sounds in anterior left lower lobe | Exam Action 04/11/25 8:26 AM EDT |
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| Auscultated breath sounds in posterior left upper lobe | Exam Action 04/11/25 8:26 AM EDT |
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| Auscultated breath sounds in posterior right upper lobe | Exam Action 04/11/25 8:26 AM EDT |
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| Auscultated breath sounds in posterior left mid-back (lower lobe) | Exam Action 04/11/25 8:26 AM EDT |
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| Auscultated breath sounds in posterior right mid-back (lower lobe) | Exam Action 04/11/25 8:26 AM EDT |
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| Auscultated breath sounds in posterior left lower lobe | Exam Action 04/11/25 8:26 AM EDT |
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| Auscultated breath sounds in posterior right lower lobe | Exam Action 04/11/25 8:26 AM EDT |
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| Auscultated breath sounds in posterior left lower lobe on side | Exam Action 04/11/25 8:26 AM EDT |
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| Auscultated breath sounds in posterior left lower lobe near spine | Exam Action 04/11/25 8:26 AM EDT |
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| Auscultated breath sounds in posterior right lower lobe near spine | Exam Action 04/11/25 8:26 AM EDT |
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| Auscultated breath sounds in posterior right lower lobe on side | Exam Action 04/11/25 8:26 AM EDT |
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| Auscultated aortic area with the bell | Exam Action 04/11/25 8:27 AM EDT |
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| Auscultated pulmonic area with the bell | Exam Action 04/11/25 8:27 AM EDT |
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| Auscultated pulmonic area with the diaphragm | Exam Action 04/11/25 8:27 AM EDT |
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| Auscultated pulmonic area with the bell | Exam Action 04/11/25 8:27 AM EDT |
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| Auscultated Erb’s point with the bell | Exam Action 04/11/25 8:27 AM EDT |
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| Auscultated Erb’s point with the diaphragm | Exam Action 04/11/25 8:27 AM EDT |
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| Auscultated tricuspid area with the diaphragm | Exam Action 04/11/25 8:27 AM EDT |
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| Auscultated mitral area with the diaphragm | Exam Action 04/11/25 8:27 AM EDT |
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| Auscultated aorta in abdomen | Exam Action 04/11/25 8:27 AM EDT |
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| Auscultated right renal pulse | Exam Action 04/11/25 8:27 AM EDT |
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| Auscultated left renal pulse | Exam Action 04/11/25 8:27 AM EDT |
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| Auscultated right iliac pulse | Exam Action 04/11/25 8:27 AM EDT |
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| Auscultated left iliac pulse | Exam Action 04/11/25 8:27 AM EDT |
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| Auscultated right femoral pulse | Exam Action 04/11/25 8:28 AM EDT |
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| Auscultated left femoral pulse | Exam Action 04/11/25 8:28 AM EDT |
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| Tested ABI: 141/145 = 0.972 | Exam Action 04/11/25 8:28 AM EDT |
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| Performed EKG: Regular sinus rhythm, no ST changes | Exam Action 04/11/25 8:28 AM EDT |
Subjective Data Collection: 19 of 19 (100.0%)
Hover To Reveal…
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
- Found:
Indicates an item that you found.
- Available:
Indicates an item that is available to be found.
Category
Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.
Chief Complaint
Finding:
Established chief complaint
Finding:
Reports recent episodes of palpitations
(Found)
Pro Tip: Broad questions like this one enable the patient to establish their chief complaint. Asking Tina if she’s had any problems with her heart will allow her to mention any concerns she’s recently had regarding her heart.
Example Question:
Have you ever had palpitations?
Finding:
Describes heart rate during episodes as feeling “faster than usual”
(Found)
Pro Tip: Broad questions like this one enable the patient to establish their chief complaint. Asking Tina if she’s had any problems with her heart will allow her to mention any concerns she’s recently had regarding her heart.
Example Question:
Have you had any problems with your heart?
History of Presenting Illness
Finding:
Asked about onset
Finding:
Reports first episode a month ago
(Found)
Pro Tip: Determining the onset of a health problem is the first step to understanding if the underlying condition is acute or chronic.
Example Question:
How long ago did you start having palpitations?
Finding:
Asked about frequency and duration of fast heartbeat episodes
Finding:
Reports episodes occur “about once a week”
(Found)
Pro Tip: Conditions, like palpitations, might change over time. Asking Tina when her palpitations began will give you a broader sense for her condition and her chief complaint.
Example Question:
When do the palpitations occur?
Finding:
Reports 3-4 episodes total
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina how many palpitation episodes she’s experienced in the last month specifies the way her individual symptoms manifest.
Example Question:
How many palpitation episodes have you had?
Finding:
Reports fast heartbeat episodes last 5-10 minutes
(Available)
Pro Tip: Conditions, like palpitations, might change over time. Asking Tina about the duration of her palpitations recently will allow you to assess the recent severity of her condition.
Example Question:
How long do your palpitations last?
Finding:
Asked about character of palpitations
Finding:
Describes palpitations as “thumping” or “pounding”
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe her palpitations specifies the way her individual symptoms manifest.
Example Question:
How does your heart feel during the palpitations?
Finding:
Reports episodes accompanied by mild anxiety
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina whether she is anxious during her palpitations specifies the way her individual symptoms manifest.
Example Question:
Do you feel anxious during the palpitations?
Finding:
Asked about aggravating factors
Finding:
Reports that palpitations seem to occur more often in the morning
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe when her palpitations began specifies the way her individual symptoms manifest.
Example Question:
When do you feel the palpitations?
Finding:
Reports episodes not exacerbated by exertion
(Available)
Pro Tip: Conditions, like palpitations, might change over time. Asking Tina if the palpitations are worse with exertion will allow you to assess the recent severity of her condition.
Example Question:
Do the palpitations get worse with exertion?
Finding:
Reports that episodes do not occur after eating
(Available)
Pro Tip: Some people experience palpitation after eating certain foods. Asking Tina whether she experiences palpitations after eating might indicate she is sensitive to certain foods (like foods that are spicy or contain MSG or caffeine).
Example Question:
Does food make your palpitations worse?
Finding:
Reports caffeine as a possible aggravating factor
(Found)
Pro Tip: Some people who drink caffeinated beverages have higher blood pressure than those who don’t drink caffeinated beverages. Asking Tina whether the caffeine is affecting her heart rate might point to the caffeine as a contributing factor to Tina’s palpitations.
Example Question:
Does the caffeine affect your heart rate?
Finding:
Asked about relieving factors
Finding:
Reports deep breathing and trying to relax
(Found)
Pro Tip: By asking Tina what relieves her palpitations you’re soliciting information about the way she treats, manages, or endures an uncomfortable symptom.
Example Question:
What relieves your palpitations?
Finding:
Denies medication or other treatment
(Available)
Pro Tip: Tina’s response to a question about the management of her palpitations will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.
Example Question:
What treatments have you tried for your palpitations?
Medical History
Finding:
Confirmed use of medications
Finding:
Confirms medications from previous visit
(Found)
Pro Tip: Determining what, if any, medications a patient is taking is a crucial element of a thorough health history and will help you avoid unwanted drug interactions.
Example Question:
Have you started any new medications?
Finding:
Reports new inhaler
(Found)
Pro Tip: Determining what, if any, medications a patient is taking is a crucial element of a thorough health history and will help you avoid unwanted drug interactions.
Example Question:
Do you use an inhaler?
Finding:
Followed up on new inhaler
Finding:
New inhaler is Flovent
(Found)
Pro Tip: You must find out the specific name or brand of a patient’s medication.
Example Question:
What is the name of your daily inhaler?
Finding:
Prescribed dose is two puffs
(Available)
Pro Tip: When you ask about the specific dosage that a patient is supposed to take, you learn more about their medication regiment, and their level of health literacy surrounding medication use.
Example Question:
How many puffs do you take of your inhaler?
Finding:
Inhaler is prescribed for daily use
(Available)
Pro Tip: Increased inhaler use, or using more puffs of an inhaler than prescribed, can indicate poorly managed asthma.
Example Question:
How often do you use your inhaler?
Finding:
Describes new inhaler regiment as effective
(Available)
Pro Tip: Finding out the patient’s perception of how effective an inhaler is gives you insight into how they feel their asthma is managed.
Example Question:
Is your inhaler working?
Finding:
Confirmed allergies
Finding:
Confirms allergies (no new allergies reported)
(Found)
Pro Tip: It’s best practice to ask a patient about her allergies each visit, even with an established patient, to uncover any new allergy triggers or symptoms.
Example Question:
Have you had any new allergies?
Finding:
Asked about personal history of hypertension
Finding:
Reports usual blood pressure “might be on the high side”
(Available)
Pro Tip: Blood pressure might change over time due to such factors as caffeine consumption, stress, diet, and exercise. Asking Tina what her usual blood pressure is will provide a baseline for comparing her last reading to her blood pressure now.
Example Question:
What is your usual blood pressure?
Finding:
Denies past diagnosis of hypertension
(Found)
Pro Tip: Cardiovascular disease can manifest in various conditions. Inquiring into Tina’s relevant history can reveal past diagnoses and previous conditions or concerns.
Example Question:
Have you been diagnosed with high blood pressure?
Finding:
Does not check BP regularly
(Found)
Pro Tip: Blood pressure might change over time due to such factors as caffeine consumption, stress, diet, and exercise. Asking Tina how frequently she checks her blood pressure will show how often she is monitoring her cardiovascular health.
Example Question:
How often do you check your blood pressure?
Finding:
Is aware of risk factors for hypertension
(Available)
Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking Tina if she is aware that her family history of hypertension puts her at risk for cardiovascular disease indicates Tina’s health literacy.
Example Question:
Do you know your family history of high blood pressure is a risk factor for heart disease?
Finding:
Asked about possible contributing factors in health history
Finding:
Reports no known history of heart disease
(Available)
Pro Tip: Heart disease is the umbrella term to describe many conditions that might affect your heart. Asking Tina whether she has a history of heart disease is the first question in determining her specific cardiovascular concerns.
Example Question:
Do you have any history of heart disease
Finding:
Reports type 2 diabetes
(Found)
Pro Tip: Adults with diabetes are between two and four times more likely to suffer from cardiovascular disease. Determining whether Tina has diabetes will indicate if she is at a higher risk for heart disease.
Example Question:
Do you have diabetes?
Finding:
Reports no past diagnosis of high cholesterol
(Available)
Pro Tip: High cholesterol can lead to cardiovascular disease. Asking Tina whether she’s had a history of high cholesterol reveals her recent medical history.
Example Question:
Do you have high cholesterol?
Finding:
Reports no history of rheumatic fever
(Available)
Pro Tip: Rheumatic fever can cause irreversible damage to the heart. Asking Tina whether she’s had rheumatic fever would point to a condition that might have affected her cardiovascular health.
Example Question:
Do you have any history of rheumatic fever?
Finding:
Reports no history of heart murmur
(Found)
Pro Tip: Some heart murmurs can indicate a damaged or overworked heart valve. Asking Tina whether she’s experienced a heart murmur allows you to assess whether she’s noticed a symptom that indicates a heart condition.
Example Question:
Do you have any history of heart murmur?
Finding:
Reports no EKG or other diagnostic cardiac tests
(Available)
Pro Tip: An EKG test checks for electrical problems with the heart. Asking Tina whether she’s had an EKG will reveal her recent medical history and medical literacy.
Example Question:
Have you ever had an EKG?
Social Determinants of Health
Finding:
Asked about stress and anxiety
Finding:
Reports occasional feelings of anxiety
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
Have you ever experienced anxiety?
Finding:
Reports recent increase in stress
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
Have you been more stressed lately?
Finding:
Reports stress related to school and work
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
What causes you stress?
Social History
Finding:
Asked about typical diet
Finding:
Breakfast is usually a muffin or pumpkin bread
(Available)
Pro Tip: A healthy and balanced diet is crucial in the prevention of heart disease. Asking Tina about her typical breakfast will allow you to assess whether her eating habits put her at risk of cardiovascular disease.
Example Question:
What’s your usual breakfast?
Finding:
Lunch is usually a sandwich
(Available)
Pro Tip: A healthy and balanced diet is crucial in the prevention of heart disease. Asking Tina about her typical lunch will allow you to assess whether her eating habits put her at risk of cardiovascular disease.
Example Question:
What’s your usual lunch?
Finding:
Dinner is usually a home-cooked meat dish and side of vegetables
(Available)
Pro Tip: A healthy and balanced diet is crucial in the prevention of heart disease. Asking Tina about her typical dinner will allow you to assess whether her eating habits put her at risk of cardiovascular disease.
Example Question:
What’s your usual dinner?
Finding:
Snacks are pretzels or French fries
(Available)
Pro Tip: A healthy and balanced diet is crucial in the prevention of heart disease. Asking Tina about her typical snacks will allow you to assess whether her eating habits put her at risk of cardiovascular disease.
Example Question:
What’s your usual snack?
Finding:
Asked about caffeine consumption
Finding:
Reports increased caffeine consumption
(Available)
Pro Tip: Drinking more caffeine might point to underlying conditions like increased fatigue. Asking why Tina is drinking more caffeine will indicate a context for broader physical or mental health concerns.
Example Question:
Have you been drinking more caffeine lately?
Finding:
Reports consuming diet soda or energy drinks
(Found)
Pro Tip: Diet soda consumption has been linked to heart disease. Asking Tina if she drinks soda allows you to assess if her dietary habits put her at increased risk for cardiovascular disease.
Example Question:
Do you drink soda?
Finding:
Reports caffeine increase was over last month
(Available)
Pro Tip: Some people who drink caffeinated beverages have higher blood pressure than those who don’t drink caffeinated beverages. Asking Tina how long she has been drinking more caffeine might point to the caffeine as a contributing factor to Tina’s palpitations.
Example Question:
How long have you been drinking more caffeine?
Finding:
Typical drinks 2 energy drinks before class
(Found)
Pro Tip: Most energy drinks have more caffeine per ounce than caffeine found in coffee or tea. Asking Tina about her energy drink consumption will indicate whether she is consuming too many energy drinks.
Example Question:
How many energy drinks do you drink in a day?
Finding:
Reports caffeine “keeps me focused but sometimes makes me jittery”
(Available)
Pro Tip: Some people who drink caffeinated beverages have higher blood pressure than those who don’t drink caffeinated beverages. Asking Tina about how caffeine affects her will indicate whether Tina’s caffeine habits might be linked to her cardiac condition.
Example Question:
What effect does caffeine have on you?
Finding:
Asked about exercise and activity level
Finding:
Reports general low activity level
(Found)
Pro Tip: Regular exercise, when paired with a healthy diet, is one of the most effective ways to limit the risk of cardiovascular disease. Asking Tina whether she exercises will reveal her lifestyle and level of fitness, two factors that are fundamental to a healthy cardiovascular system.
Example Question:
Do you exercise?
Finding:
Asked about substance use
Finding:
Reports occasional consumption of alcohol
(Found)
Pro Tip: Alcohol consumption can cause palpitations in certain types of conditions. Asking about consumption can help you determine if it’s a factor in this patient’s case.
Example Question:
Do you ever drink alcohol?
Finding:
Last alcoholic drink was two weeks ago
(Available)
Pro Tip: Use of nicotine-containing products can cause cardiovascular problems. Asking about use can help you determine if it’s a factor in this patient’s case.
Example Question:
When did you last have alcohol?
Finding:
Denies history of tobacco use, including cigarettes
(Found)
Pro Tip: Tobacco affects the heart by reducing the amount of oxygen the blood is able to carry. Asking Tina if she uses tobacco will allow you to assess whether the condition is caused, in part, by tobacco use.
Example Question:
Do you use tobacco?
Finding:
Denies drug use
(Found)
Pro Tip: Many drugs affect the central nervous system or can cause cardiovascular complications. Asking Tina if she uses illicit drugs will indicate whether drug use is a factor in her palpitations.
Example Question:
Do you use drugs?
Review of Systems
Finding:
Asked about general symptoms
Finding:
Denies recent respiratory or other illness
(Available)
Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing.
Example Question:
Have you been sick recently?
Finding:
Denies fever
(Available)
Pro Tip: The presence or absence of fever can indicate if an infection is approaching sepsis, a life-threatening condition.
Example Question:
Have you had any fever symptoms?
Finding:
Denies nausea or vomitting
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like nausea, details the way her individual symptoms and pain manifest.
Example Question:
Have you had nausea or vomiting?
Finding:
Denies chills
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like getting chills, details the way her individual symptoms and pain manifest.
Example Question:
Have you had chills?
Finding:
Reports low energy level
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like fatigue, details the way her individual symptoms and pain manifest.
Example Question:
Are you fatigued?
Finding:
Denies night sweats
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her injury, like night sweats, details the way her individual symptoms and pain manifest.
Example Question:
Have you had night sweats?
Finding:
Asked about review of systems for cardiovascular
Finding:
Denies shortness of breath
(Found)
Pro Tip: Conditions, like palpitations, might change over time. Asking Tina whether she has shortness of breath during palpitations will allow you to assess the recent severity of her condition.
Example Question:
Do you have any shortness of breath during the palpitations?
Finding:
Denies chest pain or tightness
(Found)
Pro Tip: Chest pain manifests in various ways, from a muted ache to a stabbing pain. Asking Tina whether she’s had chest pain can point to such conditions as angina or heart attack, among others.
Example Question:
Have you ever had any chest pain?
Finding:
Denies edema
(Found)
Pro Tip: When the heart weakens and pumps blood less effective, the resulting fluid that accumulates can lead to edema. Asking Tina whether she’s experienced edema allows you to assess if her heart is pumping less effectively.
Example Question:
Have you ever had any swelling?
Finding:
Denies circulation problems
(Found)
Pro Tip: Poor circulation is the result of other diseases like obesity, diabetes, or cardiac conditions. Asking Tina whether she’s experienced poor circulation indicates whether she might suffer from underlying cardiac concerns.
Example Question:
Have you ever had problems with circulation?
Finding:
Denies easy bleeding or bruising
(Available)
Pro Tip: Bleeding or bruising easily means that the capillaries under the skin break easily and often and can be indicative of a severe blood disorder. Asking Tina whether she has been bleeding easily allows you to assess other conditions that might be affecting her chief complaint.
Example Question:
Do you bleed easily?
Finding:
Denies dizziness, lightheadedness, or syncope
(Available)
Pro Tip: Lightheadedness might be a symptom of arrhythmias. Asking Tina whether she has a history of lightheadedness illustrates her medical history relating to her chief complaint.
Example Question:
Have you had any lightheadedness?
Family History
Finding:
Asked about relevant family history
Finding:
Reports family history of heart disease or CAD
(Found)
Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina’s family has a history of high cholesterol might reveal her health literacy and predisposition to heart disease.
Example Question:
Do you have a family history of coronary artery disease?
Finding:
Reports family history of high cholesterol
(Available)
Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina’s family has a history of hypertension might reveal her health literacy and predisposition to heart disease.
Example Question:
Do you have a family history of high cholesterol?
Finding:
Reports family history of hypertension
(Available)
Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina’s family has a history of myocardial infarction might reveal her health literacy and predisposition to heart disease.
Example Question:
Do you have a family history of high blood pressure?
Finding:
Reports family history of myocardial infarction
(Found)
Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina’s family has a history of coronary artery disease might reveal her health literacy and predisposition to heart disease.
Example Question:
Do you have a family history of heart attack?
Finding:
Reports family history of stroke
(Available)
Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina’s family has a history of stroke might reveal her health literacy and predisposition to heart disease.
Example Question:
Do you have a family history of stroke?
Finding:
Reports family history of obesity
Objective Data Collection: 22.17 of 23 (96.39%)
- Correct
- Partially correct
- Incorrect
- Missed
Symmetry (1/2 point)
- Symmetric
Appearance (1/2 point)
- No visible abnormal findings
Inspected for jugular venous distention
Height Of Venous Pressure (1/1 point)
- 4 cm or less above the sternal angle
Inspected hands and fingernails
Right: Nail Changes (1/3 point)
- No visible abnormal findings
Left: Nail Changes (1/3 point)
- No visible abnormal findings
Capillary Refill Time (1/3 point)
- 3 seconds or less
Inspected lower extremities and toenails
Right: Edema (No point)
- No edema
Right: Severity Of Edema (No point)
- No edema
Right: Appearance (No point)
- No visible abnormal findings
Right: Nail Changes (1/9 point)
- No visible abnormal findings
- Left: Edema (1/9 point)
- No edema
Left: Severity Of Edema (1/9 point)
- No edema
Left: Appearance (1/9 point)
- No visible abnormal findings
Left: Nail Changes (1/9 point)
- No visible abnormal findings
Capillary Refill Time (1/9 point)
- 3 seconds or less
Right: Vibration (1/4 point)
- No thrill
Right: Amplitude (1/4 point)
- 2+ Expected
Left: Vibration (1/4 point)
- No thrill
Left: Amplitude (1/4 point)
- 2+ Expected
Right: Vibration (1/4 point)
- No thrill
Right: Amplitude (1/4 point)
- 2+ Expected
Left: Vibration (1/4 point)
- No thrill
Left: Amplitude (1/4 point)
- 2+ Expected
Location (1/3 point)
- Present at midclavicular line and 5th intercostal space
Amplitude (1/3 point)
- Brisk and tapping
Diameter (1/3 point)
- Less than 3 cm
Right: Vibration (1/4 point)
- No thrill
Right: Amplitude (1/4 point)
- 2+ Expected
Left: Vibration (1/4 point)
- No thrill
Left: Amplitude (1/4 point)
- 2+ Expected
Right: Vibration (1/4 point)
- No thrill
Right: Amplitude (1/4 point)
- 2+ Expected
Left: Vibration (1/4 point)
- No thrill
Left: Amplitude (1/4 point)
- 2+ Expected
Right: Vibration (1/4 point)
- No thrill
- Thrill
Right: Amplitude (1/4 point)
- 2+ Expected
Left: Vibration (1/4 point)
- No thrill
Left: Amplitude (1/4 point)
- 2+ Expected
Right: Vibration (1/4 point)
- No thrill
Right: Amplitude (1/4 point)
- 2+ Expected
Left: Vibration (1/4 point)
- No thrill
Left: Amplitude (1/4 point)
- 2+ Expected
Right: Vibration (1/4 point)
- No thrill
Right: Amplitude (No point)
- 2+ Expected
Left: Vibration (1/4 point)
- No thrill
Left: Amplitude (1/4 point)
- 2+ Expected
Palpated dorsalis pedis arteries
Right: Vibration (1/4 point)
- No thrill
Right: Amplitude (No point)
- 2+ Expected
Left: Vibration (1/4 point)
- No thrill
- Thrill
Left: Amplitude (1/4 point)
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
Right (1/2 point)
- No bruit
Left (1/2 point)
- No bruit
Right (1/2 point)
- No bruit
Left (1/2 point)
- No bruit
Breath Sounds (1/3 point)
- Present in all areas
Adventitious Sounds (1/3 point)
- No adventitious sounds
Location (1/3 point)
- All areas clear
Heart Sounds (1/2 point)
- S1 and S2 audible
Extra Heart Sounds (1/2 point)
- No extra sounds
Sounds (1/1 point)
- No bruit
Right (1/2 point)
- No bruit
Left (1/2 point)
- No bruit
Right (1/2 point)
- No bruit
Left (1/2 point)
- No bruit
Right (1/2 point)
- No bruit
Left (1/2 point)
- No bruit
Performed ankle-brachial index test
Abi (1/1 point)
- 0.90 – 0.99 (borderline ischemia)
Sinus Rhythm (1/2 point)
- Regular
St Changes (1/2 point)
- No ST changes
Education & Empathy : 1 of 5 (20.0%)
During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A Model Statement is provided as an example of an appropriate response to each opportunity.
- Opportunities marked as Not Encountered are opportunities that were not elicited in the interview
- Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were made
- Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient
| Description: Tina describes the symptoms that have been bothering her. | ||
| When do the palpitations occur? | Question 08:13 AM EDT |
|
| I’ve only noticed them in the mornings, usually on the way to class. Maybe like once a week. | ||
| How does your heart feel during the palpitations? | Question 08:14 AM EDT |
|
| Well, my heart doesn’t hurt, but it feels like thumping. Just a fast, thumping heartbeat, I guess. | ||
| What is the name of your daily inhaler? | Question 08:15 AM EDT |
|
| The daily inhaler is Flovent, and the rescue inhaler is Proventil. | ||
| Exercise is health for your body and can help relief stress | Educate 08:15 AM EDT |
|
| Alright, thanks for letting me know. | ||
| A family history of hypertension means that you may be at risk of developing it and its therefore important to monitor it. | Educate 08:16 AM EDT |
|
| OK, I understand. | ||
| Model Statement: “I’m sorry to hear you’re experiencing those symptoms; they can be very uncomfortable. I’ll ask you some questions to learn more about your symptoms, and we will try to determine what’s causing you to feel this way.” |
| Description: Tina has signs of hypertension and a strong family history of the disease, but does not take any action. | ||
| Do you have a history of hypertension | Question 08:07 AM EDT |
|
| …I’ve never been diagnosed with blood pressure problems. But I think it can be on the high side sometimes. | ||
| Do you check your blood pressure? | Question 08:07 AM EDT |
|
| Only when I’m here at the clinic. | ||
| Do you have diabetes? | Question 08:07 AM EDT |
|
| Yeah, I was diagnosed a few years ago. | ||
| Do you have any stress? | Question 08:08 AM EDT |
|
| Model Statement: “A family history of hypertension means that you may be at risk for developing it, too, and you’ve had some high blood pressure readings. Keeping your blood pressure low is important to avoid health problems in the future with your heart and other organs.” |
| Description: Tina describes being busy, anxious, and stressed out. | ||
| Do you have any stress? | Question 08:08 AM EDT |
|
| Yeah, I’ve been pretty stressed lately. | ||
| Do you exercise? | Question 08:08 AM EDT |
|
| Model Statement: “Sounds like you’re working really hard. I’m sorry you’re dealing with so much stress.” |
| Description: Tina drinks a high level of caffeine and does not stay hydrated with water. | ||
| Do you drink coffee? | Question 07:59 AM EDT |
|
| Never. I don’t like it. Too bitter for my taste. I drink energy drinks instead. | ||
| How many energy drinks do you drink per day? | Question 07:59 AM EDT |
|
| Usually just one in the morning, kind of like some people have a cup of coffee. Some mornings lately I’ve had two, though. | ||
| Do you use drugs? | Question 07:59 AM EDT |
|
| No. | ||
| Which medication do you use? (Clarified to: What medications do you take?) | Question 08:00 AM EDT |
|
| I have a daily inhaler and a rescue inhaler for my asthma. (Clarified to: what medications I am taking) | ||
| Model Statement: “Drinking high levels of caffeine can make you feel stressed or anxious, and can dehydrate you. Over time, lots of caffeine can make you experience “crashes” during the day, too. Let’s talk about healthy alternatives.” |
| Description: Tina does not exercise on a regular basis. | ||
| Do you exercise? | Question 08:08 AM EDT |
|
| I’m pretty exhausted by the end of the day, so I don’t have the energy to do any extra exercise. But I’m on my feet all the time at work so I feel like that’s a little bit of exercise most days at least. | ||
| Do you drink alcohol? | Question 08:08 AM EDT |
|
| I do sometimes, yeah, when I go out with my friends. | ||
| When do the palpitations occur? | Question 08:13 AM EDT |
|
| Model Statement: “I understand being busy and having very little free time. However, exercise is healthy for you, and can even relieve stress. Even small amounts of exercise, such as taking a short walk, can improve your health.” |
Documentation / Electronic Health Record
Document: Provider Notes
| Student Documentation | Model Documentation |
| Subjective
Tina JOnes present to the clinit with complaints of 3-4 episodes of rapid heart rates over the last month. She says it feels like “thumping in her chest” with a heart rate “way faster than usual”. This usually happens once per week. The episodes last between 5 to 10 minutes. She denies SOB. Has not taken any medications. She has increased consumption of energy drinks to 2 drinks before class to help being focused. She does not use tobacco, alcohol, and illicit drugs. She does not exercise. |
Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of 3-4 episodes of rapid heart rate over the last month. She is a good historian. She describes these episodes as “thumping in her chest” with a heart rate that is “way faster than usual”. She does not associate the rapid heart rate with a specific event, but notes that they usually occur about once per week in the morning on her commute to class. The episodes generally last between 5 and 10 minutes and resolve spontaneously. She does not know her normal heart rate or her heart rate during these episodes. She denies chest pain during the episodes, but does endorse discomfort of 3/10 which she attributes to associated anxiety regarding her rapid heart rate. She denies shortness of breath. She denies any association of symptoms with exertion. She has no known cardiac history and has never had episodes prior to this last month. She has not attempted any treatment at home and states that she is only coming to the clinic today because her family has expressed concern regarding these episodes. Social History: Ms. Jones has a job at a copy and shipping store and is a student at Shadowville Community College. She states that she has been feeling more “stressed” lately due to her school and work. She has been feeling tired at the end of the day. She denies any specific changes in her diet recently, but notes that she has not been drinking as much water as her normal. Breakfast is usually a muffin or pumpkin bread, lunch is a sandwich, dinner is a homemade meal of a meat and vegetable, snacks are French fries or pretzels. Over the past month she has increased her consumption of diet soda and “energy” drinks due to her feelings of tiredness. She generally drinks 2 energy drinks before class to “keep her focused” but states that they also make her “jittery”. She denies use of tobacco, alcohol, and illicit drugs. She does not exercise. Review of Systems: General: Denies changes in weight, but complains of end of day fatigue. She denies fevers, chills, and night sweats. She complains of intermittent dizziness. • Cardiac: Denies a diagnosis of hypertension, but states that she has been told her blood pressure was high in the past. She checks it at CVS periodically. At last check it was “140/80 or 90”. She denies known history of murmurs, angina, previous palpitations, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or edema. She has never had an EKG. • Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16 for asthma, last chest XR was age 16. • Hematologic: She denies history of anemia, easy bruising or bleeding, petechiae, purpura, or blood transfusions. |
| Objective
Ms. Jones is a pleasant African American woman. She is in no acute distress. She is alert and well oriented. PMI is non-displace, brisk and tapping, diameter 2 cm Regular rate and rhythm, S1 amd S2 present, no murmurs, rubs, gallops, precordial movements, pulses 2+ and equal bilaterally. No thrills. No temporal, carotid, abdominal aorta, femoral, renal bruits, No JVD, No peripheral edema, EKG with regurlar sinus rhythm, no ST changes, ABI is 0.97 |
• General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination. • Cardiovascular: PMI is non-displaced, brisk and tapping, diameter 2 cm. Regular rate and rhythm, S1 and S2 present, no murmurs, rubs, gallops, clinics, precordial movements. Pulses 2+ and equal bilaterally in upper extremities and lower extremities without thrills. No temporal, carotid, abdominal aorta, femoral, iliac, or renal bruits. No JVD. Capillary refill < 3 seconds. No peripheral edema. EKG with regular sinus rhythm, no ST changes. ABI is 0.97. • Respiratory: Chest is symmetrical with respirations; no physical abnormalities present on chest wall. Lung sounds clear to auscultation without wheezes, crackles, or cough. |
| Assessment
Palpitations related to caffeine and anxiety |
Palpitations related to caffeine and/or anxiety |
| Plan
– Continue monitoting symptoms – Obtain EKG to rule out cardiac abnormality – Decrease caffeine consumption – Educate on anxiety reduction strategies – Maintain a stable blood pressure – continue monitoring – Seek care when you notice symptoms – Revisit clinic in 2-4 weeks |
Encourage Ms. Jones to continue to monitor symptoms and log her episodes of palpitations with associated factors and bring log to next visit. • Obtain EKG to rule out any cardiac abnormality and assess for symptom-correlated EKG changes. If inconclusive, consider ambulatory EKG monitoring and referral to cardiology. • Encourage to decrease caffeine consumption and increase intake of water and other fluids. • Educate on anxiety reduction strategies including deep breathing, relaxation, and guided imagery. Continue to monitor and explore the need for possible referral to social work/psychiatry or pharmacologic intervention. • Discuss the need to maintain a stable blood pressure. Encourage Ms. Jones to continue to monitor her blood pressure when a cuff or machine is available. • Educate Ms. Jones on when to seek emergent care including episodes of chest pain unrelieved by rest, palpitations that do not dissipate after anxiety related strategies were implemented, changes in vision, loss of consciousness, and sense of impending doom. • Revisit clinic in 2-4 weeks for follow up and evaluation. |
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