Brian Foster Focused Exam: Chest Pain Health Assessment – January 2023

Transcript

All Lines (144)Interview Questions (48)Statements (2)Exam Actions (94)

	Hello!
	Hi. I’m Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript.
	What is the situation?
	Your patient is Brian Foster, a 58-year-old Caucasian man. He has been hospitalized in Shadow General Hospital for 3 days after a TURP, or Transurethral resection of the prostate. Today, he started having chest pain. Your role in this simulation is that of a healthcare provider who will conduct a focused history and physical examination of Mr. Foster in order to assess his condition and transfer his care. While Mr. Foster’s condition is critical, he will survive this exam.
	What are my objectives in this assessment?
	In your interview with Brian, you will ask about the history of his presenting illness and the functioning of relevant systems in order to obtain subjective data related to his chest pain. If you discover any disease states, ask about symptoms and the patient’s experiences of them. Your questioning should cover a broad array of the symptoms’ characteristics. You will also inquire into the health history of Mr. Foster’s family so you can determine his genetic disposition to any diseases. In addition to collecting subjective data, you will perform a physical exam on Mr. Foster to gather objective data about his health and physiology. Throughout the conversation, you should educate and empathize with Mr. Foster when appropriate to increase his health literacy and sense of well-being. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed.
	What else will this exam involve?
	You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for your colleagues who will attend to the patient. You may record Mr. Foster’s vitals as you see fit, as they will fluctuate throughout the exam. If you believe Mr. Foster to be in danger, you may press the button reading Notify the Preceptor. Do not end the exam until you have collected all relevant subjective and objective data. After the exam, you will transfer care of the patient to me, Preceptor Diana, communicating key information about the Situation, Background, Assessment, and Recommendation, or SBAR. Activities other than Subjective and Objective Data Collection, and Education and Empathy, provide valuable practice for their real-world counterparts. However, they are not automatically graded by the simulation.
	How will I be evaluated?
	In this assignment, you will be evaluated on your Subjective and Objective Data Collection, as well as Education and Empathy. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record. Your success in Education and Empathy is based on whether you promptly respond after identifying a moment worthy of therapeutic communication. This assignment takes on average between 45 and 60 minutes. You can pause and resume the assignment at any time; your work is always saved automatically.
	How does this assignment prepare me for the real world?
	In this assessment, you will become familiarized with the structure and content of a chest pain focused exam so that with real-life patients, you can: º ask effective and comprehensive questions º educate and empathize with the patient º evaluate the patient’s risk of disease, infection, injury, and complications º obtain and assess objective data. º and transfer patient care using SBAR.
	In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: What are 3-5 common causes of chest pain?
	Inflammation
	Time to begin.
	Hello, how are you? My name is Nukol I will be your nurse today.
	Hi.
	What is your name?
	Brian Robert Foster.
	What brings you here today?
	I’m having a really uncomfortable pressure in my chest right now.
	I am sorry for that
	Thank you.
	WHen did the problem start?
	Only about five minutes ago.
	where is the pain located?
	I feel it mostly in the middle of my chest, over my heart. There’s a little bit of ache in my left shoulder, but it’s the chest pain that’s really worrying me.
	Measured vitals
	Tested blood pressure in left arm with cuff
	Tested blood pressure in right arm with cuff
	Measured vitals
	how frequent is the chest pain?
	It’s the first time. It’s terrible.
	How severe is the pain?
	It’s really tight and uncomfortable. Maybe like a 6 out of 10.
	what are the aggravating factors of the pain?
	I don’t really know, I only noticed it a few minutes ago. I tried to get up and walk around the room a little but I think that made it worse.
	what are the relieving factors of the pain? (Clarified to What relieves your symptoms?.)
	It seems like moving around makes it worse, or at least more noticeable. I felt a little better when I sat down to rest for a few minutes. (Clarified to what relieves my symptoms.)
	what relieves the pain?
	I’m not sure. I think lying still seems to help a little.
	do you have allergies?
	No, well…I’ve had a bad reaction to codeine before, but that is all I know of.
	do you have any other medical conditions?
	Well I thought it was just my prostate, and I hope this chest pain isn’t much of a problem. I take meds for blood pressure and cholesterol too.
	do you monitor blood pressure?
	Not usually. They check it when I get checkups. My doctor has never seemed overly concerned about it.
	monitoring blood pressure frequently is very important
	Sure.
	have you had cardiac test?
	I’ve had…huh…well, I guess I’ve had the EKG a few times and they give me a stress test every two years or so.
	what were the results of the cardiac test?
	Everything was normal, they said.
	have you taken any medications? (Clarified to Have you taken medication for the pain?.)
	No, not yet. (Clarified to if I took medication for the pain.)
	have you taken home medications?
	Um…I think it’s on the chart, but this morning they gave me Lisinopril, some ibuprofen, some hydrocodone, and, um, the stool softener. Oh, and the Lovenox.
	Is the high blood pressure medication helpful? (Clarified to What dose of medication do you take for high high blood pressure?.)
	It’s 20 milligrams once a day. (Clarified to what the dosage of my high blood pressure medication is.)
	do you use cholesterol medication?
	I take Atorvastatin.
	how is your access to healthcare?
	Yes.
	do you have stress?
	Honestly, my life is pretty low stress. My job rarely stresses me out, my home life is great, and my kids generally behave. My only stress right now is this chest pain.
	do you exercise?
	Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I haven’t had much regular exercise since then…I want to get a new bike after I recover from this surgery.
	what is your typical diet?
	I think my diet’s alright. My wife says I should do better but I’m a meat man, what can I say.
	do you take a lot of fluids? (Clarified to Do you drink a lot of fluids?.)
	I usually drink water all day at work. At least a liter, probably more. (Clarified to if I drink a lot of fluids.)
	do you use drugs?
	Nope.
	Do you drink alcohol?
	Sure, but never more than two or three beers on a weekend.
	How many drinks do you take?
	I rarely drink during the week. If I drink at all it’s a couple beers on the weekend while I’m grilling or watching football. Maybe a little bourbon occasionally.
	Do you have a family history of chest pain?
	Now? In my immediate family? Not that I know of. I don’t think this is a . . . contagious condition.
	how is your constitutional health?
	I don’t think anything’s wrong besides this chest pain. . .
	how is your respiratory system?
	My breathing’s fine.
	How is your mouth, nose, eyes and ears? (No matching questions found.)
	do you have any headache?
	I get headaches once in a blue moon, but it’s never anything that has concerned me.
	how is your gastrointestinal system?
	I think it’s okay.
	how is your ears? (Clarified to How is your vision?.)
	I think it’s still fine. I’ve never hd to wear glasses. (Clarified to how my vision is.)
	how are your ears and nose? (Clarified to Do your ears hurt?.)
	No. (Clarified to if I have ear pain.)
	how is your cardiovascular system?
	I don’t know–I thought fine, but my chest is hurting, so. . .
	How is the systems for HEENT?
	I think it’s okay.
	do you take a lot of fluids? (Clarified to Do you take over the counter medications a lot?.)
	I wouldn’t say a lot, no. (Clarified to if I take over the counter medication a lot.)
	do you take a lot of fluids? (Clarified to Do you drink a lot of fluids?.)
	I usually drink water all day at work. At least a liter, probably more. (Clarified to if I drink a lot of fluids.)
	do you have any eye problem?
	No, I don’t think so.
	do you have any nose problem?
	No.
	Inspected face
	Inspected for jugular venous distension: No jugular venous distention; JVP 1 cm above sternal angle
	Inspected anterior chest wall
	Inspected right side chest wall
	Inspected posterior chest wall
	Inspected left side chest wall
	Inspected anterior chest wall
	Inspected left side chest wall
	Inspected posterior chest wall
	Inspected right side chest wall
	Inspected anterior chest wall
	Inspected right hand
	Inspected left hand
	Inspected fingernails of left hand
	Inspected fingernails of right hand
	Inspected right leg
	Inspected left leg
	Inspected toenails on right foot
	Inspected toenails on left foot
	Inspected left leg for edema: No edema
	Inspected right leg for edema: No edema
	Checked capillary refill in fingernails
	Checked capillary refill in fingernails
	Checked capillary refill in fingernails
	Checked capillary refill in fingernails
	Checked capillary refill in fingernails
	Checked capillary refill in fingernails
	Checked capillary refill in fingernails
	Checked capillary refill in fingernails
	Checked capillary refill in toenails
	Checked capillary refill in toenails
	Checked capillary refill in toenails
	Checked capillary refill in toenails
	Checked capillary refill in toenails
	Checked capillary refill in toenails
	Checked capillary refill in toenails
	Checked capillary refill in toenails
	Checked capillary refill in toenails
	Checked capillary refill in toenails
	Checked capillary refill in toenails
	Palpated left carotid pulse: No thrill, 2+
	Palpated right carotid pulse: No thrill, 2+
	Palpated PMI: Displaced laterally; brisk and tapping; less than 3 cm
	Palpated right brachial pulse: No thrill, 2+
	Palpated left brachial pulse: No thrill, 2+
	Palpated right radial pulse: No thrill, 2+
	Palpated left radial pulse: No thrill, 2+
	Palpated right radial pulse: No thrill, 2+
	Palpated right femoral pulse: No thrill, 2+
	Palpated left femoral pulse: No thrill, 2+
	Palpated right popliteal pulse: No thrill, 2+
	Palpated left popliteal pulse: No thrill, 2+
	Palpated right tibial pulse: No thrill, 1+
	Palpated left tibial pulse: No thrill, 1+
	Palpated right dorsalis pedis pulse: No thrill, 1+
	Palpated left dorsalis pedis pulse: No thrill, 1+
	Auscultated right carotid pulse
	Auscultated left carotid pulse
	Auscultated aortic area with the bell
	Auscultated pulmonic area with the bell
	Auscultated Erb’s point with the bell
	Auscultated Erb’s point with the diaphragm
	Auscultated tricuspid area with the diaphragm
	Auscultated tricuspid area with the bell
	Auscultated mitral area with the bell
	Auscultated mitral area with the diaphragm
	Auscultated aorta in abdomen
	Auscultated right renal pulse
	Auscultated left renal pulse
	Auscultated right iliac pulse
	Auscultated left iliac pulse
	Auscultated right femoral pulse
	Auscultated left femoral pulse
	Auscultated breath sounds in anterior right upper lobe
	Auscultated breath sounds in anterior left upper lobe
	Auscultated breath sounds in anterior right middle lobe
	Auscultated breath sounds in anterior left mid-chest (upper lobe)
	Auscultated breath sounds in anterior right lower lobe
	Auscultated breath sounds in anterior left lower lobe
	Auscultated breath sounds in posterior left upper lobe
	Auscultated breath sounds in posterior right upper lobe
	Auscultated breath sounds in posterior left mid-back (lower lobe)
	Auscultated breath sounds in posterior right mid-back (lower lobe)
	Auscultated breath sounds in posterior left lower lobe
	Auscultated breath sounds in posterior right lower lobe
	Auscultated breath sounds in posterior right lower lobe on side
	Auscultated breath sounds in posterior right lower lobe near spine
	Auscultated breath sounds in posterior left lower lobe near spine
	Auscultated breath sounds in posterior left lower lobe on side
	Performed EKG
	What is your recent meal?
	My wife brought me some buffalo wings last night around eight.
	Do you have any throat problem?
	Nope.

 

Subjective Data Collection: 23 of 23 (100.0%)

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 chest pain

(Found)

Pro Tip: Asking a patient broadly about their chief complaint allows them to answer in their own words and confirm information that you may have already received from another source.

Example Question:

Do you have chest pain?

History of Presenting Illness

Finding:

Asked about onset and duration of chest pain

Finding:

Reports chest pain started about five minutes ago

(Found)

Pro Tip: Establishing the onset of a patient’s chest pain is essential in diagnosing its severity as well as the comfort of the patient.

Example Question:

When did the chest pain start?

Finding:

Reports chest pain has been constant since it began

(Available)

Pro Tip: Knowing the duration of a patient’s pain gives you a more complete picture of its severity and potential impact on the patient’s health.

Example Question:

How long does the chest pain last?

Finding:

Reports sitting in bed when pain began

(Available)

Pro Tip: A patient’s position and posture when their pain began can inform you as to the nature of the pain, as pain upon exertion often has different causes than pain upon resting.

Example Question:

Were you sitting when the pain began?

Finding:

Asked to rate chest pain on a scale

Finding:

Reports current pain is 6/10

(Found)

Pro Tip: For many patients, it is difficult to clearly describe pain. Asking Brian to rate his pain on a scale from 0 to 10 develops a consistent measure of pain severity.

Example Question:

On a scale of 0 to 10 how would you rate the chest pain?

Finding:

Asked about on characteristics of the pain

Finding:

Describes pain as tight and uncomfortable

(Found)

Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning.

Example Question:

Can you describe your pain?

Finding:

Denies crushing pain

(Available)

Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning.

Example Question:

Is the pain crushing?

Finding:

Denies gnawing or tearing pain

(Available)

Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning.

Example Question:

Is the pain gnawing?

Finding:

Denies burning pain

(Available)

Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning.

Example Question:

Is the pain burning?

Finding:

Asked about location of the pain

Finding:

Reports pain location is in middle of the chest

(Found)

Pro Tip: Identifying the location of a patient’s pain is essential in determining which body systems are affected, the underlying cause of the pain, and how best to treat it.

Example Question:

Where is the pain?

Finding:

Reports slight pain in left shoulder

(Found)

Pro Tip: Pain radiation is an important symptom that can be helpful in understanding the cause of pain and narrowing the diagnosis.

Example Question:

Does the pain radiate?

Finding:

Denies arm pain

(Available)

Pro Tip: When combined with chest pain, arm pain can be a telling sign that the complaint may be cardiac in nature.

Example Question:

Do you have arm pain?

Finding:

Denies back pain

(Available)

Pro Tip: When combined with chest pain, back pain can be a telling sign that the complaint may be cardiac in nature.

Example Question:

Do you have back pain?

Finding:

Denies jaw pain

(Available)

Pro Tip: When combined with chest pain, jaw pain can be a telling sign that the complaint may be cardiac in nature.

Example Question:

Do you have jaw pain?

Finding:

Denies neck pain

(Available)

Pro Tip: When combined with chest pain, neck pain can be a telling sign that the complaint may be cardiac in nature.

Example Question:

Do you have neck pain?

Finding:

Asked about pain triggers

Finding:

Reports pain is aggravated by exertion

(Found)

Pro Tip: Aggravating factors reveal further information about the nature of the pain and the body systems affected.

Example Question:

What makes the pain worse?

Finding:

Asked about stress and anxiety

Finding:

Reports generally low stress lifestyle

(Found)

Pro Tip: Stress can have a profound effect on the patient’s health and wellness. Asking about stress is an important part of any health assessment.

Example Question:

What is your usual stress level?

Finding:

Denies history of anxiety

(Available)

Pro Tip: Symptoms such as chest pain can be caused or exacerbated by episodes of anxiety. Asking Brian if he’s ever suffered from anxiety can point to underlying stressors or triggers.

Example Question:

Do you have a history of anxiety?

Finding:

Denies history of panic attacks

(Available)

Pro Tip: Symptoms such as chest pain can be caused or exacerbated by episodes of anxiety. Asking Brian if he’s ever had a panic attack can point to underlying stressors or triggers.

Example Question:

Have you ever had a panic attack?

Past Medical History

Finding:

Asked relevant health history

Finding:

Reports high blood pressure

(Found)

Pro Tip: Hypertension is the most important risk factor for stroke. Soliciting a health history from Brian will allow you to assess his risk of cardiovascular disease.

Example Question:

Do you have high blood pressure?

Finding:

Reports high cholesterol

(Found)

Pro Tip: High cholesterol can lead to cardiovascular disease. Asking Brian whether he’s had a history of high cholesterol reveals important details about his cardiovascular health.

Example Question:

Do you have high cholesterol?

Finding:

Denies history of pulmonary embolism

(Available)

Pro Tip: Pulmonary embolism is one of many cardiac risk factors to ask about that can help you form a more complete picture of Brian’s cardiovascular health.

Example Question:

Have you ever had a pulmonary embolism?

Finding:

Denies history of angina

(Available)

Pro Tip: A history of angina can weaken the heart and lead to further cardiovascular complications. Asking Brian about angina helps you understand his overall cardiovascular health.

Example Question:

Do you have a history of angina?

Finding:

Denies history of rheumatic fever

(Available)

Pro Tip: Rheumatic fever early in life can cause fibrosis of the heart valves and can weaken the cardiovascular system. Finding out if Brian has a history of rheumatic fever is crucial to understanding his complete heart health.

Example Question:

Do you have a history of rheumatic fever?

Finding:

Denies history of heart murmur

(Available)

Pro Tip: Heart murmurs can be harmless or a sign of ongoing heart disease. Learning if Brian has a heart murmur is an important component of understanding his complete cardiovascular health.

Example Question:

Do you have a history of heart murmur?

Finding:

Followed up on high blood pressure treatment

Finding:

Reports taking high blood pressure medication

(Found)

Pro Tip: The medication that a patient takes for their high blood pressure will indicate how well controlled their condition is and how well they comply with treatment regimens.

Example Question:

Do you take medication for high blood pressure?

Finding:

Reports high blood pressure medication is Lisinopril

(Available)

Pro Tip: Discovering what specific high blood pressure medication a patient takes helps you assess his health conditions, effectiveness of treatment, and guards against unwanted medication interactions.

Example Question:

What medication do you take for high blood pressure?

Finding:

High blood pressure medication dose is 20mg

(Found)

Pro Tip: The current dose of any patient’s high blood pressure medication is important to learn about because it provides useful information about the patient’s treatment plan as well as potential medication interactions.

Example Question:

What dose of medication do you take for high blood pressure?

Finding:

High blood pressure medication is taken once daily

(Found)

Pro Tip: The frequency with which a patient takes his high blood pressure medications is an essential element of the complete picture of his medication treatment plan.

Example Question:

How frequently do you take medication for high blood pressure?

Finding:

Followed up on high cholesterol treatment

Finding:

Reports taking high cholesterol medication

(Found)

Pro Tip: The medication that a patient takes for their high cholesterol will indicate how well controlled their condition is and how well they comply with treatment regimens.

Example Question:

Do you take medication for cholesterol?

Finding:

Reports high cholesterol medication is Atorvastatin (Lipitor)

(Found)

Pro Tip: Discovering what specific high cholesterol medication a patient takes helps you assess his health conditions, effectiveness of treatment, and guards against unwanted medication interactions.

Example Question:

What medication do you take for cholesterol?

Finding:

Reports high cholesterol medication dose is 20mg

(Available)

Pro Tip: The current dose of any patient’s high cholesterol medication is important to learn about because it provides useful information about the patient’s treatment plan as well as potential medication interactions.

Example Question:

What dose of medication do you take for cholesterol?

Finding:

Reports high cholesterol medication is taken once daily

(Available)

Pro Tip: The frequency with which a patient takes his high cholesterol medications is an essential element of the complete picture of his medication treatment plan.

Example Question:

How frequently do you take medication for cholesterol?

Finding:

Asked history of cardiac tests

Finding:

Reports recent EKG test

(Found)

Pro Tip: An EKG test checks for electrical problems with the heart. Asking Brian whether he’s had an EKG will reveal his recent medical history, cardiac health, and medical literacy.

Example Question:

Have you recently had an EKG test?

Finding:

Reports undergoing a stress test within last two years

(Found)

Pro Tip: A stress test can illustrate the amount of stress a patient’s heart can handle before developing irregular rhythm. Asking Brian if he’s recently had a stress test will indicate a treatment plan, cardiac health, and health literacy.

Example Question:

Have you recently had a stress test?

Finding:

Asked about results of cardiac tests

Finding:

Reports belief that EKG was normal

(Available)

Pro Tip: An EKG test checks for electrical problems with the heart. Asking Brian whether he’s had an EKG will reveal his recent medical history, cardiac health, and medical literacy.

Example Question:

What were the results of your last EKG?

Finding:

Reports belief that stress test was normal

(Available)

Pro Tip: A stress test can illustrate the amount of stress a patient’s heart can handle before developing irregular rhythm. Asking Brian if he’s recently had a stress test will indicate a treatment plan, cardiac health, and health literacy.

Example Question:

What were the results of your last stress test?

Finding:

Asked about substance use

Finding:

Denies illicit drug use

(Found)

Pro Tip: Many drugs affect the central nervous system or can cause cardiovascular complications. Asking Brian if he uses illicit drugs will indicate whether drug use puts him at risk for health complications.

Example Question:

Do you use illicit drugs?

Finding:

Denies tobacco use

(Available)

Pro Tip: Tobacco affects the heart by reducing the amount of oxygen the blood is able to carry. Asking Brian if he uses tobacco will allow you to assess whether the condition is caused, in part, by tobacco use.

Example Question:

Do you use tobacco?

Finding:

Reports moderate alcohol consumption

(Found)

Pro Tip: Chronic alcohol use can result in cardiomyopathy. Asking Brian whether he drinks alcohol will allow you to assess whether he has any indicators of alcoholism.

Example Question:

How much alcohol do you consume?

Finding:

Followed up on alcohol consumption

Finding:

Reports drinking only on weekends

(Found)

Pro Tip: Asking the patient to describe his drinking habits can identify indicators of alcoholism. It may also be helpful to ask about the context and reasons for the patient’s alcohol intake. Heavy drinkers will often underestimate their drinking habits.

Example Question:

How frequently do you drink alcohol?

Finding:

Reports drinking 2-4 alcoholic drinks per week

(Found)

Pro Tip: Consumption of alcohol can impact a patient’s health and is considered a risk factor for many medical conditions. Asking Brian about his drinking habits will help you determine his risk for disease linked to alcohol consumption.

Example Question:

How many alcoholic drinks do you have in a week?

Finding:

Reports 2-3 drinks in a single sitting

(Found)

Pro Tip: Asking the patient to quantify his drinking is helpful because it elicits objective data on a subject that patients may otherwise downplay.

Example Question:

How many alcoholic drinks do you consume at a time?

Finding:

Asked about exercise

Finding:

Denies having a regular exercise routine

(Found)

Pro Tip: Activity levels have an important impact on cardiovascular health. Asking Brian about his exercise patterns can help you understand how his lifestyle might affect his health.

Example Question:

What kind of exercise do you get?

Finding:

Asked about most recent meal

Finding:

Reports most recent meal was previous night at 8 p.m.

(Found)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Brian about his most recent meal will allow you to assess whether his eating habits put him at risk of cardiovascular disease or other health complications, and can reveal if the food he ate may be affecting his complaint.

Example Question:

What time was your last meal?

Finding:

Reports meal consisted of buffalo wings

(Found)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Brian about his most recent meal will allow you to assess whether his eating habits put him at risk of cardiovascular disease or other health complications, and can reveal if the food he ate may be affecting his complaint.

Example Question:

What did you eat last night?

Finding:

Asked about typical diet

Finding:

Reports typical breakfast is granola bar and instant breakfast shake

(Available)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Brian about his typical breakfast will allow you to assess whether his eating habits put him at risk of cardiovascular disease or other health complications.

Example Question:

What is a typical breakfast for you?

Finding:

Reports typical lunch is turkey sub

(Available)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Brian about his typical lunch will allow you to assess whether his eating habits put him at risk of cardiovascular disease or other health complications.

Example Question:

What is a typical lunch for you?

Finding:

Reports typical dinner is grilled meat and vegetables

(Available)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Brian about his typical dinner will allow you to assess whether his eating habits put him at risk of cardiovascular disease or other health complications.

Example Question:

What is a typical dinner for you?

Finding:

Denies moderating salt intake

(Available)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Salt intake in particular can have a detrimental effect on blood pressure, which is why it is important to ask a patient like Brian, who suffers from hypertension, about his salt consumption.

Example Question:

Do you moderate your salt intake?

Review of Systems

Finding:

Asked about review of cardiovascular system

Finding:

Denies palpitations

(Available)

Pro Tip: Discovering palpitations can be an important clue into the patient’s cardiovascular history and current condition.

Example Question:

Do you have palpitations?

Finding:

Denies swelling

(Available)

Pro Tip: Swelling can be a major indicator of cardiovascular and peripheral vascular health. Asking the patient about swelling is an important part of a thorough cardio exam.

Example Question:

Do you have any swelling?

Finding:

Denies circulation problems

(Available)

Pro Tip: Circulation is an important indicator of peripheral vascular and cardiovascular health. Asking Brian about his circulation can help diagnose vascular conditions.

Example Question:

Do you have any problems with circulation?

Finding:

Denies blood clots

(Available)

Pro Tip: Blood clots can be a sign of serious cardiovascular or related illnesses. Asking Brian about blood clots can provide valuable information about the state of his health.

Example Question:

Have you ever had a blood clot?

Finding:

Denies easy bleeding

(Available)

Pro Tip: Bleeding can be a sign of serious cardiovascular or related illnesses. Asking Brian about bleeding can provide valuable information about the state of his cardiovascular health.

Example Question:

Have you noticed any unusual bleeding?

Finding:

Denies easy bruising

(Available)

Pro Tip: Ease of bruising can be a sign of serious cardiovascular or related illnesses. Asking Brian about bruising can provide valuable information about the state of his cardiovascular health.

Example Question:

Have you noticed any unusual bruising?

Finding:

Asked about constitutional health

Finding:

Denies fever

(Available)

Pro Tip: Fever can signify infection and other complications, so it is important to determine the presence of a fever and treat it if there is.

Example Question:

Do you have a fever?

Finding:

Denies chills

(Available)

Pro Tip: Chills can be a sign of circulation issues, fever, and more. Discovering a patient’s chills will reveal more about the cause of his complaint.

Example Question:

Do you have chills?

Finding:

Denies fatigue

(Available)

Pro Tip: Fatigue can be an indicator of serious cardiovascular problems, and it is important to ask the patient about it in order to narrow your diagnosis.

Example Question:

Do you feel tired?

Finding:

Denies sleep issues

(Available)

Pro Tip: Sleep issues can be an indicator of serious cardiovascular problems, and it is important to ask the patient about it in order to narrow your diagnosis.

Example Question:

Have you had problems sleeping?

Finding:

Denies recent weight changes

(Available)

Pro Tip: Weight changes can be an indicator of serious cardiovascular problems, and it is important to ask the patient about it in order to narrow your diagnosis.

Example Question:

Has your weight changed?

Finding:

Denies night sweats

(Available)

Pro Tip: Night sweats can be an indicator of serious cardiovascular problems, and it is important to ask the patient about it in order to narrow your diagnosis.

Example Question:

Do you have night sweats?

Finding:

Denies dizziness or lightheadedness

(Available)

Pro Tip: Patients exhibiting dizziness may be at risk for several conditions as well as a fall risk. It is important to ask about dizziness to keep your patient safe.

Example Question:

Do you have dizziness?

Finding:

Asked about review of respiratory system

Finding:

Denies cough

(Available)

Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the respiratory system. A cough in a patient complaining of chest pain is a symptom worth investigating.

Example Question:

Do you have a cough?

Finding:

Denies shortness of breath while lying down

(Found)

Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the respiratory system. Orthopnea in a patient complaining of chest pain is a symptom worth investigating.

Example Question:

Do you have difficulty breathing when lying down?

Finding:

Denies blue skin

(Available)

Pro Tip: Cyanosis can be a symptom of troubling cardiovascular illness, though patients may not be aware of its connection to respiratory health. Asking Brian if he has noticed any cyanosis is important in ruling out certain cardiac risk factors.

Example Question:

Has your skin ever turned blue?

Finding:

Asked about throat problems

Finding:

Denies sore throat

(Found)

Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the throat. A sore throat in a patient complaining of chest pain is a symptom worth investigating.

Example Question:

Do you have a sore throat?

Finding:

Denies difficulty swallowing

(Found)

Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the throat. Painful or difficult swallowing in a patient complaining of chest pain is a symptom worth investigating.

Example Question:

Do you have difficulty swallowing?

Finding:

Asked about review of gastrointestinal system

Finding:

Denies diarrhea

(Available)

Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the gastrointestinal system. Diarrhea in a patient complaining of chest pain is a symptom worth investigating.

Example Question:

Do you have diarrhea?

Finding:

Denies constipation

(Available)

Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the gastrointestinal system. Constipation in a patient complaining of chest pain is a symptom worth investigating.

Example Question:

Do you have constipation?

Finding:

Denies flatus

(Available)

Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the gastrointestinal system. Excessive gas in a patient complaining of chest pain is a symptom worth investigating.

Example Question:

Do you have flatulence?

Finding:

Denies bloating

(Available)

Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the gastrointestinal system. A patient complaining of bloating in addition to chest pain is a symptom worth investigating.

Example Question:

Do you have bloating?

Finding:

Denies heartburn or GERD

(Available)

Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the gastrointestinal system. Heartburn and GERD are of particular importance to ask about, since their symptoms closely follow the symptoms of cardiac pain.

Example Question:

Do you have heartburn or GERD?

Finding:

Reports earlier nausea

(Available)

Pro Tip: Nausea can be an urgent symptom and sign of distress in more than one body symptom. Assessing and treating a patient’s nausea is important in a cardiovascular exam.

Example Question:

Do you have nausea?

Finding:

Denies vomiting

(Available)

Pro Tip: Vomiting can be a major indicator of multiple health problems. Asking the patient about vomiting is an important part of a thorough cardio exam.

Example Question:

Have you vomited recently?

Family History

Finding:

Asked relevant family history

Finding:

Reports family history of heart attack

(Available)

Pro Tip: Family health history is an important genetic indicator of a patient’s predisposition to certain medical conditions. Asking Brian if anyone in his family has suffered a heart attack helps you develop a more complete picture of his cardiovascular health.

Example Question:

Has anyone in your family had a heart attack?

Finding:

Denies family history of stroke

(Available)

Pro Tip: Family health history is an important genetic indicator of a patient’s predisposition to certain medical conditions. Asking Brian if anyone in his family has suffered a stroke helps you develop a more complete picture of his cardiovascular health.

Example Question:

Do you have a family history of stroke?

Finding:

Denies family history of pulmonary embolism

Objective Data Collection: 21 of 21 (100%)

•  Correct
•  Partially correct

•  Incorrect
•  Missed

 Inspected face

1 of 1 point

 

Appearance (1/1 point)

•  No visible abnormal findings
•  Rash or lesion
•  Cyanosis
•  Pallor
•  Redness or flushing
•  Evidence of trauma (scar, laceration, or bruising)

 Inspected for jugular venous distension

1 of 1 point

 

Height Of Venous Pressure (1/1 point)

•  4 cm or less above the sternal angle
•  More than 4 cm above the sternal angle

 Inspected chest

1 of 1 point

 

Symmetry (1/2 point)

•  Symmetric
•  Asymmetric

Appearance (1/2 point)

•  No visible abnormal findings
•  Rash or lesion
•  AP diameter abnormal
•  Intercostal retraction while breathing
•  Excessive use of accessory muscles while breathing
•  Pectus excavatum
•  Skin growths (freckles or moles)
•  Evidence of skin trauma (scar, laceration, or bruising)

 Inspected hands and fingernails

1 of 1 point

 

Right: Appearance (1/4 point)

•  No visible abnormal findings
•  Redness
•  Moles or skin tags
•  Masses (warts, cysts, or tumors)
•  Freckles, birthmark, or other discoloration
•  Excessive dry or flaking skin
•  Purpura
•  Scarring
•  Laceration, lesion, or wound
•  Bruising
•  Rash

Left: Appearance (1/4 point)

•  No visible abnormal findings
•  Redness
•  Moles or skin tags
•  Masses (warts, cysts, or tumors)
•  Freckles, birthmark, or other discoloration
•  Excessive dry or flaking skin
•  Purpura
•  Scarring
•  Laceration, lesion, or wound
•  Bruising
•  Rash

Right: Nail Changes (1/4 point)

•  No visible abnormal findings
•  Pallor
•  Cyanosis
•  Splinter hemorrhages
•  Clubbing

Left: Nail Changes (1/4 point)

•  No visible abnormal findings
•  Pallor
•  Cyanosis
•  Splinter hemorrhages
•  Clubbing

 Inspected lower extremities and toenails

1 of 1 point

 

Right: Appearance (1/4 point)

•  No visible abnormal findings
•  Visible distortion or swelling
•  Brownish pigmentation
•  Skin thickening
•  Ulceration
•  Varicose veins

Right: Nail Changes (1/4 point)

•  No visible abnormal findings
•  Pallor
•  Cyanosis
•  Splinter hemorrhages
•  Clubbing

Left: Appearance (1/4 point)

•  No visible abnormal findings
•  Visible distortion or swelling
•  Brownish pigmentation
•  Skin thickening
•  Ulceration
•  Varicose veins

Left: Nail Changes (1/4 point)

•  No visible abnormal findings
•  Pallor
•  Cyanosis
•  Splinter hemorrhages
•  Clubbing

 Inspect lower extremities for edema

1 of 1 point

 

Right: Edema (1/4 point)

•  No edema
•  Pitting
•  Non-pitting

Right: Severity Of Edema (1/4 point)

•  No edema
•  1+ Slight pitting
•  2+ Deeper pit, disappears in 10 to 15 seconds
•  3+ Noticeably deep pit that lasts more than a minute
•  4+ Very deep pit that lasts 2 to 5 minutes

Left: Edema (1/4 point)

•  No edema
•  Pitting
•  Non-pitting

Left: Severity Of Edema (1/4 point)

•  No edema
•  1+ Slight pitting
•  2+ Deeper pit, disappears in 10 to 15 seconds
•  3+ Noticeably deep pit that lasts more than a minute
•  4+ Very deep pit that lasts 2 to 5 minutes

 Tested capillary refill time

1 of 1 point

 

Fingers (1/2 point)

•  Less than 3 seconds
•  Greater than 3 seconds

Toes (1/2 point)

•  Less than 3 seconds
•  Greater than 3 seconds

 Palpated carotid arteries

1 of 1 point

 

Right: Vibration (1/4 point)

•  No thrill
•  Thrill

Right: Amplitude (1/4 point)

•  0 Absent
•  1+ Diminished or barely palpable
•  2+ Expected
•  3+ Increased
•  4+ Bounding pulse

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

 Palpated PMI

1 of 1 point

 

Location (1/3 point)

•  Present at midclavicular line and 5th intercostal space
•  Displaced laterally

Diameter (1/3 point)

•  Less than 3 cm
•  Greater than 3 cm

Amplitude (1/3 point)

•  Brisk and tapping
•  Increased amplitude (hyperkinetic)

 Palpated brachial arteries

1 of 1 point

 

Right: Vibration (1/4 point)

•  No thrill
•  Thrill

Right: Amplitude (1/4 point)

•  0 Absent
•  1+ Diminished or barely palpable
•  2+ Expected
•  3+ Increased
•  4+ Bounding pulse

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

 Palpated radial arteries

1 of 1 point

 

Right: Vibration (1/4 point)

•  No thrill
•  Thrill

Right: Amplitude (1/4 point)

•  0 Absent
•  1+ Diminished or barely palpable
•  2+ Expected
•  3+ Increased
•  4+ Bounding pulse

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

 Palpated femoral arteries

1 of 1 point

 

Right: Vibration (1/4 point)

•  No thrill
•  Thrill

Right: Amplitude (1/4 point)

•  0 Absent
•  1+ Diminished or barely palpable
•  2+ Expected
•  3+ Increased
•  4+ Bounding pulse

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

 Palpated popliteal arteries

1 of 1 point

 

Right: Vibration (1/4 point)

•  No thrill
•  Thrill

Right: Amplitude (1/4 point)

•  0 Absent
•  1+ Diminished or barely palpable
•  2+ Expected
•  3+ Increased
•  4+ Bounding pulse

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

 Palpated tibial arteries

1 of 1 point

 

Right: Vibration (1/4 point)

•  No thrill
•  Thrill

Right: Amplitude (1/4 point)

•  0 Absent
•  1+ Diminished or barely palpable
•  2+ Expected
•  3+ Increased
•  4+ Bounding pulse

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

 Palpated dorsalis pedis arteries

1 of 1 point

 

Right: Vibration (1/4 point)

•  No thrill
•  Thrill

Right: Amplitude (1/4 point)

•  0 Absent
•  1+ Diminished or barely palpable
•  2+ Expected
•  3+ Increased
•  4+ Bounding pulse

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

 Auscultated carotid arteries

1 of 1 point

 

Right (1/2 point)

•  No bruit
•  Bruit

Left (1/2 point)

•  No bruit
•  Bruit

 Auscultated heart sounds

1 of 1 point

 

Heart Sounds (1/2 point)

•  S1 and S2 audible
•  S1, S2, and S3 audible
•  S1, S2, and S4 audible
•  S1, S2, S3, and S4 audible

Extra Heart Sounds (1/2 point)

•  No extra sounds
•  Gallops
•  Murmur
•  Friction rub
•  Valve clicks

 Auscultated abdominal aorta

1 of 1 point

 

Sounds (1/1 point)

•  No bruit
•  Bruit

 Auscultated abdominal and lower extremity arteries

1 of 1 point

 

Right: Renal (1/6 point)

•  No bruit
•  Bruit

Right: Iliac (1/6 point)

•  No bruit
•  Bruit

Right: Femoral (1/6 point)

•  No bruit
•  Bruit

Left: Renal (1/6 point)

•  No bruit
•  Bruit

Left: Iliac (1/6 point)

•  No bruit
•  Bruit

Left: Femoral (1/6 point)

•  No bruit
•  Bruit

 Auscultated breath sounds

1 of 1 point

 

Breath Sounds (1/3 point)

•  Present in all areas
•  Diminished in some areas
•  Absent in some areas

Adventitious Sounds (1/3 point)

•  No adventitious sounds
•  Wheezing
•  Fine crackles
•  Stridor
•  Rhonchi
•  Rales

Location (1/3 point)

•  All areas clear
•  Adventitious sounds in anterior right upper lobe
•  Adventitious sounds in anterior right middle lobe
•  Adventitious sounds in anterior right lower lobe
•  Adventitious sounds in anterior left upper lobe
•  Adventitious sounds in anterior left lower lobe
•  Adventitious sounds in posterior right upper lobe
•  Adventitious sounds in posterior right lower lobe
•  Adventitious sounds in posterior left upper lobe
•  Adventitious sounds in posterior left lower lobe

 Performed EKG

1 of 1 point

 

Sinus Rhythm (1/2 point)

•  Regular
•  Irregular

St Changes (1/2 point)

•  No ST elevation
•  ST elevation present

Education & Empathy : 1 of 4 (25.0%)

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

 1 Family Medical History

Not Encountered

 

	Description: Mr. Foster shares his emotions over his family history of illness and death.
	Model Statement: “Thank you for telling me about your family’s health. It’s clear you care for your family and hate to see them suffer, especially as it indicates your own risk factors. This medical history will help us develop a care plan for your own health.”

 2 Exercise

Not Followed Up

 

	Description: Mr. Foster reports that he does not exercise regularly.
	do you exercise?
	Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I haven’t had much regular exercise since then…I want to get a new bike after I recover from this surgery.
	what is your typical diet?
	Model Statement: “Exercise can lead to health improvements for everyone, and is helpful for people with high blood pressure and cholesterol. We can help you consider some healthy forms of exercise that you might be interested in trying.”

 3 Pain and Discomfort

Followed Up

 

	Description: Mr. Foster describes the symptoms that have been distressing him.
	WHen did the problem start?
	Only about five minutes ago.
	where is the pain located?
	I feel it mostly in the middle of my chest, over my heart. There’s a little bit of ache in my left shoulder, but it’s the chest pain that’s really worrying me.
	how frequent is the chest pain?
	It’s the first time. It’s terrible.
	How severe is the pain?
	It’s really tight and uncomfortable. Maybe like a 6 out of 10.
	what are the aggravating factors of the pain?
	I don’t really know, I only noticed it a few minutes ago. I tried to get up and walk around the room a little but I think that made it worse.
	what are the relieving factors of the pain? (Clarified to: What relieves your symptoms?)
	It seems like moving around makes it worse, or at least more noticeable. I felt a little better when I sat down to rest for a few minutes. (Clarified to: what relieves my symptoms)
	what relieves the pain?
	I’m not sure. I think lying still seems to help a little.
	do you have allergies?
	No, well…I’ve had a bad reaction to codeine before, but that is all I know of.
	do you have any other medical conditions?
	Well I thought it was just my prostate, and I hope this chest pain isn’t much of a problem. I take meds for blood pressure and cholesterol too.
	do you monitor blood pressure?
	Not usually. They check it when I get checkups. My doctor has never seemed overly concerned about it.
	monitoring blood pressure frequently is very important
	Sure.
	Model Statement: “I share your concern for these symptoms, and I’m sorry you’re under so much discomfort and stress. We’re going to assess what’s going on so we can develop a quick and appropriate treatment plan.”

 4 Nutrition

Not Followed Up

 

	Description: Mr. Foster describes his dietary habits and reveals gaps in nutrition.
	What is your recent meal?
	My wife brought me some buffalo wings last night around eight.
	Do you have any throat problem?	Question 05:27 AM MST
	Nope.
	Model Statement: “Because your diet can impact your health in many ways, it’s best to eat veggies, fruits, and whole grains, and lean proteins like fish or chicken. Reducing your intake of red meat, refined sugars, and fried foods could help increase your overall well-being.”

 

 

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