NURS 6512 Week 7 Focused Exam Chest Pain Brian Foster Results
NURS 6512 Week 7 Focused Exam: Chest Pain Brian Foster Results
Experience Overview
Patient: Brian Foster
Digital Clinical Experience Score
99.1%
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 80.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent.
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Student Performance Index
67
out of 69
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Proficiency Level:
Subjective Data Collection
out of
Objective Data Collection
out of
Education and Empathy
out of
Time
602 minutes total spent in assignment |
Interaction with patient
602 minutes
Transcript
Hi Mr Foster, My name is , I am going to examine you today.
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Greet |
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Good morning.
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What brought you here today ?
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Question |
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I have been having some troubling chest pain in my chest now and then for the past month.
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Oh I’m sorry to hear that, it should be very uncomfortable to have that pain for a whole month.
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Empathize |
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Thanks. I appreciate that.
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? (No matching questions found.)
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Question |
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What is the onset of your pain ?
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Question |
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I first noticed it earlier this month. I thought it might just be heartburn and it passed after about a couple of minutes.
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What is the exact location of the pain ?
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Question |
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When the pain happens, I feel it mostly in the middle of my chest, over my heart.
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When did you chest pain start ?
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Question |
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I first noticed it earlier this month. I thought it might just be heartburn and it passed after a couple of minutes.
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What is the exact location of the pain ?
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Question |
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When the pain happens, I feel it mostly in the middle of my chest, over my heart.
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Sorry to hear that
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Empathize |
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Thanks. I appreciate that.
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Easter pain radiates anywhere ? (Clarified to Is your pain radiating?.)
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Question |
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The pain doesn’t radiate anywhere. It’s mostly just right in the middle of my chest. (Clarified to if the pain is radiating.)
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If your arm hurts (Clarified to Do you have pain in your arm?.)
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Question |
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No, when I am having the chest pain, it’s mostly just in middle of my chest. (Clarified to if I have pain in my arm.)
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Do you have a pain in your shoulder ?
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Question |
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No, the pain hasn’t been in my shoulder.
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Do you have a back pain ?
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Question |
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I haven’t had back pain, no.
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Can you tell me the duration of the pain ? (No matching questions found.)
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Question |
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Can you describe the duration of the pain ? (Clarified to Can you tell me what the pain is like?.)
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Question |
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Well, it mostly feels tight and uncomfortable right in the middle of my chest. (Clarified to if I can tell you what the pain is like.)
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How often pain occurs ? (Clarified to How often do you have pain?.)
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Question |
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Well, it has happened three times the past month. It usually goes away after about a couple of minutes. (Clarified to how often I have pain.)
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Can you describe your pain from 0 to 10 scale ?
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Question |
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I’d say maybe a . . . 5? It’s just really uncomfortable . . . like there’s nothing I can do about it. Right now it’s like a zero though.
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Sorry to hear that
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Empathize |
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Thanks. I appreciate that.
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Can you describe your pain ?
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Question |
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Well, it mostly feels tight and uncomfortable right in the middle of my chest.
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ASA pain crashing ? (Clarified to Do you take aspirin?.)
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Question |
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I usually just take Tylenol or ibuprofen. (Clarified to if I take aspirin.)
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What is the dosage of Tylenol are you taking ?
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Question |
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Just whatever the bottle recommends for an adult.
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What is the dosage of ibuprofen you taking ? (Clarified to What is the strength of the ibuprofen you take?.)
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Question |
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Just whatever the bottle recommends for an adult. (Clarified to What strength ibuprofen I take.)
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Is it Tylenol helps ?
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Question |
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Just a couple when I get a headache, which is not very often.
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How often do you take Tylenol ?
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Question |
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I took some today . . . maybe every couple days for mild pain.
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What is the reason you’re taking ibuprofen ?
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Question |
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Just when I need it for various aches and pains. Probably not more than 3 or 4 times a month.
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Where else do you have a pain ?
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Question |
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No, when I am having the chest pain, it’s mostly just in middle of my chest.
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Do you have a pain somewhere else in your body ?
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Question |
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No, when I am having the chest pain, it’s mostly just in middle of my chest.
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What is the aggravating factors ? (Clarified to Are there any aggravating factors?.)
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Question |
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Well, the pain seems to start when I’m doing something physical . . . the first time it happened while I was doing yard work, and the second time . . . I had to take the stairs at work because the elevator broke. Both times it got better if I took a break or sat down to rest. (Clarified to if there are aggravating factors.)
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What activity triggers pain ?
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Question |
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If I’m up and moving around I definitely notice it more and it makes me feel like I should sit down and take a deep breath or something.
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He’s a pain worse when you eat ?
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Question |
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I don’t think eating has anything to do with it. One episode did happen when my wife and I were out for dinner, but it seemed to happen before we even settled. The episodes don’t seem all that related, to be honest.
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It can be a lot of triggers in your diet which would aggravate and trigger your pain Mr.Foster.
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Educate |
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Good to know. Thank you.
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Do you like spicy food ?
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Question |
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Sure, I like spicy food. I don’t eat it very often, though. Maybe once or twice a month.
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Do you like high-fat food ? (Clarified to Do fatty foods cause the pain?.)
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Question |
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I don’t think that has anything to do with it, but I guess I don’t know. (Clarified to if fatty foods cause the pain.)
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What relieves your pain ?
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Question |
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I’m not sure. I think lying still seems to help a little.
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Take anything for chest pain ?
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Question |
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No, not yet.
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Do you take medication for hypertension ?
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Question |
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I take metoprolol, yes. [AUDIO COMING SOON]
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Is a dosage of Metoprolol ? (Clarified to What dose of Lopressor do you take?.)
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Question |
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I think it’s 100 mg, once a day. (Clarified to what dose of Lopressor I take.)
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Do you take any medication for hyperlipidemia ?
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Question |
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I take atorvastatin. [AUDIO COMING SOON]
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What is the dosage of atorvastatin are you taking ?
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Question |
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I think it’s twenty milligrams a day.
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Do you take over-the-counter medications ?
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Question |
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Oh, just ibuprofen or Tylenol occasionally for pain.
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Do you take any supplements ?
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Question |
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I take fish oil, that’s it.
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How frequently you take medication for hyperlipidemia ? (Clarified to Do you take cholesterol medication?.)
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Question |
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I take atorvastatin. [AUDIO COMING SOON] (Clarified to if I take cholesterol medication.)
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How often do you take atorvastatin ?
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Question |
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I take them daily. I’m pretty good about following the doctor’s orders.
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When have you been diagnosed with high blood pressure ?
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Question |
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Yes, I supposedly have moderately high blood pressure.
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When you started to take metoprolol ?
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Question |
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I think it’s been about one year.
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When have you been diagnosed with hyperlipidemia ? (Clarified to Do you have an anxiety disorder?.)
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Question |
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I’ve never had any anxiety problems before. [AUDIO COMING SOON] (Clarified to if I have an anxiety disorder.)
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When have you been diagnosed with hyperlipidemia ? (Clarified to Are you diagnosed with high blood pressure?.)
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Question |
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Yes, I supposedly have moderately high blood pressure. (Clarified to if I have been diagnosed with hypertension.)
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I’m sorry to hear that
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Empathize |
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Thanks. I appreciate that.
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Do you do exercise ?
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Question |
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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 if the doctor says it is OK to exercise with this chest pain I’ve been having.
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I’m sorry to hear that your bike was stolen
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Empathize |
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Thanks. I appreciate that.
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When did the exercise last time ?
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Question |
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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 if the doctor says it is OK to exercise with this chest pain I’ve been having.
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What type of food do you like ?
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Question |
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Um, let’s see . . . For breakfast I usually eat a granola bar and drink an instant breakfast shake. I’ve been doing that a while since it saves time in the morning. Most days for lunch I get a sandwich from the sub shop near work. That’s usually a turkey sub, but sometimes I get a spicy Italian sub. My wife and I grill a lot, and usually have some grilled meat with veggies for dinner.
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United include a lot of processed and fast food which is not good for your body. To have the same fast food diet may affect you over the time. You need to change your diet.
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Educate |
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Good to know. Thank you.
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You need to exercise.Not essential to do that with a bike. You can do sit ups, running or just simple indoor exercises in your home.
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Educate |
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Good to know. Thank you.
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Did you lose any weight ? (Clarified to Have you lost weight?.)
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Question |
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Not exactly . . . I’ve gained about fifteen to twenty pounds in the last couple years. (Clarified to if I have lost weight.)
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It’s not good to gain the weight. You need to change the diet and start doing the exercises.
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Educate |
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Good to know. Thank you.
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What’s what’s your fathers health ?
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Question |
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He really wasn’t doing so great in the last few years. He died when he was 75 of colon cancer, but even before that, his weight and his blood pressure and cholesterol were getting the best of him. It was rough. He didn’t last too long after the cancer diagnosis, unfortunately. I think he was tired of fighting.
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I’m sorry to hear that it should be very difficult to lose the father
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Empathize |
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Thanks. I appreciate that.
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How did you cope with a losing father ? (No matching questions found.)
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Question |
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How did you cope after you lost your father ?
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Question |
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Yeah. He died of colon cancer. He also had high blood pressure and high cholesterol.
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Sorry to hear that
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Empathize |
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Thanks. I appreciate that.
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Who’s your mother’s health ?
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Question |
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She has type 2 diabetes and some high blood pressure, but I think she’s doing pretty well for 80.
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Do you have a brothers and sisters ?
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Question |
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I have a sister, and I had a brother but he died many years ago.
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Sorry to hear that
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Empathize |
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Thanks. I appreciate that.
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How was your maternal grandmother ? (Clarified to How is the health of your maternal grandmother?.)
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Question |
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She had breast cancer. She was in her 60s when she died. (Clarified to how my maternal grandmother’s health is.)
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About maternal grandfather ?
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Question |
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My grandfather on my mom’s side died of a heart attack. He was in his mid-fifties.
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Sorry to hear that
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Empathize |
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Thanks. I appreciate that.
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How is your paternal grandfather ?
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Question |
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He was healthy right up until he died. He went in his sleep at 85, and we just called it old age.
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Sorry to hear that
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Empathize |
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Thanks. I appreciate that.
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How about fraternal grandmother ? (No matching questions found.)
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Question |
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How about paternal grandmother ?
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Question |
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She died of pneumonia when she was almost 80. 78 or 79, I think.
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Sorry to hear that
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Empathize |
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Thanks. I appreciate that.
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Do you have children ?
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Question |
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Yes, I have two great kids. Well, they’re not kids. Sam is 26 and Allie is 19.
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Does it have any medical conditions ?
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Question |
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The doctors told me I have a little bit of high blood pressure and cholesterol, but that’s it.
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Is your daughter healthy ?
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Question |
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Allie’s doing great. She has asthma, but she’s got a handle on it. [AUDIO COMING SOON]
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How is your son doing ?
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Question |
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He’s 26.
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Do you smoke ?
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Question |
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Nope, I had a lot of friends who did but I never started.
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Do you drink ?
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Question |
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Sure, but never more than two or three beers on a weekend.
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Do you do drugs ?
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Question |
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Nope.
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Do you have any hobby ?
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Question |
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I like to fish, I like sports . . . let’s see, I do some small electronics repair sometimes, and I go to my son’s bodybuilding competitions when I can.
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Did you have any surgeries ?
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Question |
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I’ve never had any surgeries.
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It is very good that you dont have any surgeries
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Empathize |
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Thanks. I appreciate that.
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Do you have any allergy ?
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Question |
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No, well . . . I’ve had a bad reaction to codeine before, but that is all I know of.
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What type of reaction do you have to codeine ?
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Question |
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It makes me nauseous and I vomit.
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How was your immunizations ? (Clarified to What immunizations have you had?.)
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Question |
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I don’t remember exactly . . . maybe it’s on my chart. (Clarified to what vaccines I have had.)
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She hasn’t been told that your cholesterol is always high ?
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Question |
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I’ve been told it’s moderately high. I’ve never noticed any actual symptoms from that though.
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Have you been tested for diabetes ?
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Question |
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My mom and my sister both have diabetes, but I don’t have it.
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Have you been monitoring your blood pressure ?
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Question |
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Not usually. They check it when I get checkups. My doctor has never seemed overly concerned about it.
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Do you remember your last blood pressure reading ? (Clarified to Do you know your blood pressure number?.)
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Question |
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No, not offhand. (Clarified to if I know my blood pressure number.)
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You need to monitor your blood pressure and you need to know your Baseline.
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Educate |
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Good to know. Thank you.
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Have you done any EKG recently ? (No matching questions found.)
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Question |
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Did your doctor do any EKG ? (No matching questions found.)
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Question |
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Any electrocardiogram ? (No matching questions found.)
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Question |
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EKG done ? (Clarified to When was your last EKG?.)
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Question |
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I had one about three months ago. They usually put one on me at my annual physical. (Clarified to when my last EKG was.)
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Well, EKG shows your heart monitoring, it will give us an idea how is your heart works.
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Educate |
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Good to know. Thank you.
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What was the result of EKG ?
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Question |
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I don’t remember the actual results, but as far as I know, it was normal.
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Do you have a primary care provider ?
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Question |
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Dr. Melinda Smith.
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It is Good that you have one.
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Educate |
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Good to know. Thank you.
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When your last visit your primary care provider ?
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Question |
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I had a physical about 3 months ago.
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Do you have stress ?
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Question |
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Not usually, but I’m feeling pretty anxious not knowing what’s going on with my chest.
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I’m sorry to hear that
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Empathize |
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Thanks. I appreciate that.
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Do your exercise ?
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Question |
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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 if the doctor says it is OK to exercise with this chest pain I’ve been having.
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I’m sorry that chest pain makes you not exercise
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Empathize |
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Thanks. I appreciate that.
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Do you drink water regularly ?
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Question |
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I usually drink water all day at work. At least four glasses, probably more. [AUDIO COMING SOON]
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Let’s go to take water
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Educate |
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Good to know. Thank you.
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Do you drink alcohol ?
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Question |
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Sure, but never more than two or three beers on a weekend.
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That’s moderate drinking
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Educate |
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Good to know. Thank you.
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Do you have a fever ?
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Question |
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I haven’t had a fever, no.
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They have a chills ?
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Question |
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I haven’t had chills, no.
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Do you have fatigue ?
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Question |
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I’m not more tired than normal.
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Do you have night sweats ?
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Question |
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Nope, no night sweats.
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Do you have thought the dacianpalpitations ?
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Question |
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Nah, I don’t think about stuff like that. I’m happy with my life.
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Do you have palpitations ?
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Question |
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I don’t think so. I haven’t noticed any.
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Do you have angina ?
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Question |
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I’ve never been diagnosed with angina. [AUDIO COMING SOON]
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Have you ever had edema ?
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Question |
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I haven’t noticed any swelling.
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Have you had any blood clots ?
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Question |
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Not that I know of.
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Any history of rheumatic fever ?
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Question |
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No, I never had that.
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Any history of heart murmur ?
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Question |
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No, none that I know of.
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? (No matching questions found.)
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Question |
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Do you have a cough ?
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Question |
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I don’t have a cough.
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Do you have difficulty breathing ?
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Question |
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My breathing’s fine.
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Do you have sore throat ?
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Question |
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I haven’t had a sore throat in a long time.
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Do you have change in sense of taste ?
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Question |
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I can still taste things fine.
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Do you have any dysphasia ? (No matching questions found.)
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Question |
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Do you have problem with swallowing ?
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Question |
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I haven’t had any trouble swallowing.
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Do you have nausea ?
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Question |
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No, I haven’t felt nauseous. I just had pain in my chest.
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Do you have diarrhea ?
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Question |
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I have, but it is very rare for me.
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Do you have constipation ?
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Question |
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I haven’t had problems with that. I wish it were only that.
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Do you have any family history of heart attack ?
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Question |
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Well, my mom’s dad died of a heart attack. He was pretty young too.
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Do you have a family history of a stroke ?
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Question |
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No, none that I know of.
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Measured vitals
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Exam Action |
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Mr. Foster, Thank you for answering my questions now I’m going to do physical examination
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Educate |
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Good to know. Thank you.
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Tested blood pressure in left arm with cuff
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Exam Action |
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Tested blood pressure in right arm with cuff
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Measured vitals
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Exam Action |
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Inspected face
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Inspected for jugular venous distension: No jugular venous distention; JVP 3 cm above sternal angle
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Inspected anterior chest wall
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Inspected left side of abdomen
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Inspected front of abdomen
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Inspected left side of abdomen
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Inspected right hand: no visible abnormal findings
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Inspected left hand: no visible abnormal findings
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Inspected fingernails of right hand
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Inspected fingernails of left hand
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Inspected left leg
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Inspected right leg
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Inspected toenails on left foot
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Inspected toenails on right foot
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Inspected left leg
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Exam Action |
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Inspected right leg
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Exam Action |
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Inspected right leg for edema: No edema
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Exam Action |
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Inspected left leg for edema: No edema
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Checked capillary refill in fingernails
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Checked capillary refill in fingernails
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Checked capillary refill in fingernails
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Checked capillary refill in fingernails
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Checked capillary refill in fingernails
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Checked capillary refill in fingernails
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Checked capillary refill in fingernails
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Auscultated right carotid pulse: Bruit present
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Auscultated left carotid pulse
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Auscultated right carotid pulse: Bruit present
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Auscultated left carotid pulse
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Auscultated right carotid pulse: Bruit present
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Exam Action |
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Auscultated aortic area with the bell
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Auscultated pulmonic area with the bell
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Auscultated Erb’s point with the bell
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Auscultated tricuspid area with the bell
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Auscultated mitral area with the bell
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Auscultated breath sounds in anterior right upper lobe
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Auscultated breath sounds in anterior left upper lobe
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Auscultated breath sounds in anterior right middle lobe
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Auscultated breath sounds in anterior left mid-chest (upper lobe)
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Auscultated breath sounds in anterior right lower lobe
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Auscultated breath sounds in anterior left lower lobe
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Auscultated aorta in abdomen
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Auscultated right renal pulse
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Auscultated left renal pulse
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Auscultated right iliac pulse
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Auscultated left iliac pulse
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Auscultated left femoral pulse
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Auscultated right femoral pulse
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Auscultated right upper quadrant
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Auscultated left upper quadrant
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Auscultated left lower quadrant
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Auscultated right lower quadrant
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Auscultated over liver
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Auscultated over spleen
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Palpated right carotid pulse: Thrill, 3+
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Palpated left carotid pulse: No thrill, 2+
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Palpated PMI: Displaced laterally; brisk and tapping; less than 3 cm
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Palpated right brachial pulse: No thrill, 2+
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Palpated left brachial pulse: No thrill, 2+
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Palpated right radial pulse: No thrill, 2+
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Palpated left radial pulse: No thrill, 2+
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Palpated right femoral pulse: No thrill, 2+
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Palpated left femoral pulse: No thrill, 2+
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Palpated right popliteal pulse: No thrill, 1+
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Palpated left popliteal pulse: No thrill, 1+
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Palpated right tibial pulse: No thrill, 1+
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Palpated right tibial pulse: No thrill, 1+
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Palpated left tibial pulse: No thrill, 1+
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Exam Action |
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Palpated right dorsalis pedis pulse: No thrill, 1+
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Exam Action |
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Palpated left dorsalis pedis pulse: No thrill, 1+
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Exam Action |
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Palpated right upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension
|
Exam Action |
|
Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension
|
Exam Action |
|
Palpated left lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension
|
Exam Action |
|
Palpated right lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension.
|
Exam Action |
|
Percussed right upper quadrant
|
Exam Action |
|
Percussed left upper quadrant
|
Exam Action |
|
Percussed right lower quadrant
|
Exam Action |
|
Percussed left lower quadrant
|
Exam Action |
|
Percussed spleen
|
Exam Action |
|
Percussed for liver span: 7 cm in the mid-clavicular line
|
Exam Action |
|
Performed EKG
|
Exam Action |
|
Thank you Mr. Foster. I’m done with physical evaluation
|
Educate |
|
Good to know. Thank you.
|
||
Houston Foster how old are you ? (No matching questions found.)
|
Question |
|
Mr.Foster how old are you ?
|
Question |
|
I’m 58 going on 30.
|
||
Early happy birthday
|
Empathize |
|
Thanks. I appreciate that.
|
||
Is it physical activity activates the pain ?
|
Question |
|
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 if the doctor says it is OK to exercise with this chest pain I’ve been having.
|
||
Sorry to hear that
|
Empathize |
|
Thanks. I appreciate that.
|
||
What aggravates your pain ?
|
Question |
|
Well, I think it’s when I’m doing something physical most of the time. The first time it happened, my chest started hurting after I was doing some yard work. The second time happened when the elevator broke at work so I had to take the stairs. My office is on the 5th floor.
|
||
Do you like red meat ?
|
Question |
|
Yes, yes I do.
|
||
Do you like vegetables and fruits ?
|
Educate |
|
Good to know. Thank you.
|
||
Do you like fruits and vegetables ? (No matching questions found.)
|
Question |
|
If your diet include fruits and vegetables ? (No matching questions found.)
|
Question |
|
You need to cut to read me like a beef pork and lamb because this meat is saturated with a bad cholesterol or fat. More than chicken and fish. Saturated and transfat can raise your blood cholesterol and make your heart disease worse.
|
Educate |
|
Good to know. Thank you.
|
||
You can replace the red meat by chicken or fish like a salmon which has a good cholesterol which which will help you to reduce your bad cholesterol and help you with your heart and cholesterol problems.
|
Educate |
|
Good to know. Thank you.
|
||
You need to start light exercising.
|
Educate |
|
Good to know. Thank you.
|
||
You need to include fresh vegetables and fruit in your diet.
|
Educate |
|
Good to know. Thank you.
|
||
You also need to continue taking your medications as prescribed.
|
Educate |
|
Good to know. Thank you.
|
||
You also need to wait yourself daily in the same clothes in the same time.
|
Educate |
|
Good to know. Thank you.
|
||
You need to do light exercise has three to four times a week.
|
Educate |
|
Good to know. Thank you.
|
||
Mister Foster you need to follow up with a primary care physician and a cardiologist. (No matching questions found.)
|
Question |
|
Mister Foster you need to follow up with a primary care physician and a cardiologist.
|
Educate |
|
Good to know. Thank you.
|
||
You also need to eliminate you alcoholic beverages.
|
Educate |
|
Good to know. Thank you.
|
||
What is your height and weight ?
|
Question |
|
I’m five foot eleven.
|
||
What is your weight ?
|
Question |
|
As of this morning, a buck ninety-seven.
|
||
I am done with your exam Mr.Foster. Thank you for letting me to examine you. Have a good day. (No matching questions found.)
|
Question |
|
I am done with your exam Mr.Foster. Thank you for letting me to examine you. Have a good day.
|
Educate |
|
EducateSpeech
|
||
Mr. Foster I just wanted to partially examine you again (No matching questions found.)
|
Question |
|
Mr. Foster I just wanted to partially examine you again
|
Educate |
|
EducateSpeech
|
||
Auscultated over liver
|
Exam Action |
|
Auscultated over spleen
|
Exam Action |
|
Auscultated over liver
|
Exam Action |
|
Percussed right upper quadrant
|
Exam Action |
|
Percussed left upper quadrant
|
Exam Action |
|
Percussed right lower quadrant
|
Exam Action |
|
Percussed left lower quadrant
|
Exam Action |
|
Thank you Mr. Foster. I am done.
|
Educate |
|
EducateSpeech
|
||
Percussed spleen
|
Exam Action |
|
Percussed spleen
|
Exam Action |
|
Inspected left leg
|
Exam Action |
|
Inspected right leg
|
Exam Action |
|
Inspected toenails on left foot
|
Exam Action |
|
Inspected left leg
|
Exam Action |
|
Inspected right leg
|
Exam Action |
|
Inspected toenails on right foot
|
Exam Action |
|
Inspected left leg
|
Exam Action |
|
Inspected right leg
|
Exam Action |
|
Inspected toenails on left foot
|
Exam Action |
|
Inspected right leg for edema: No edema
|
Exam Action |
|
Inspected left leg for edema: No edema
|
Exam Action |
|
Auscultated aortic area with the bell
|
Exam Action |
|
Auscultated pulmonic area with the bell
|
Exam Action |
|
Auscultated Erb’s point with the bell
|
Exam Action |
|
Auscultated tricuspid area with the bell
|
Exam Action |
|
Auscultated mitral area with the bell
|
Exam Action |
|
Auscultated aortic area with the bell
|
Exam Action |
|
Auscultated pulmonic area with the bell
|
Exam Action |
|
Auscultated Erb’s point with the bell
|
Exam Action |
|
Auscultated tricuspid area with the bell
|
Exam Action |
|
Auscultated mitral area with the bell
|
Exam Action |
|
Percussed right upper quadrant
|
Exam Action |
|
Percussed left upper quadrant
|
Exam Action |
|
Percussed right lower quadrant
|
Exam Action |
|
Percussed left lower quadrant
|
Exam Action |
|
Inspected left leg
|
Exam Action |
|
Inspected right leg
|
Exam Action |
|
Inspected toenails on left foot
|
Exam Action |
|
Inspected toenails on right foot
|
Exam Action |
|
Inspected toenails on left foot
|
Exam Action |
|
Inspected toenails on right foot
|
Exam Action |
|
Inspected left leg
|
Exam Action |
|
Inspected right leg
|
Exam Action |
|
Inspected right leg for edema: No edema
|
Exam Action |
|
Inspected left leg for edema: No edema
|
Exam Action |
|
Measured vitals
|
Exam Action |
|
Palpated right carotid pulse: Thrill, 3+
|
Exam Action |
|
Palpated left carotid pulse: No thrill, 2+
|
Exam Action |
|
Palpated right carotid pulse: Thrill, 3+
|
Exam Action |
|
Palpated right carotid pulse: Thrill, 3+
|
Exam Action |
|
Palpated left carotid pulse: No thrill, 2+
|
Exam Action |
|
Palpated left carotid pulse: No thrill, 2+
|
Exam Action |
|
Auscultated aortic area with the bell
|
Exam Action |
|
Auscultated pulmonic area with the bell
|
Exam Action |
|
Auscultated Erb’s point with the bell
|
Exam Action |
|
Auscultated tricuspid area with the bell
|
Exam Action |
|
Auscultated mitral area with the bell
|
Exam Action |
|
Auscultated mitral area with the diaphragm
|
Exam Action |
|
Auscultated mitral area with the bell
|
Exam Action |
|
Auscultated tricuspid area with the bell
|
Exam Action |
|
Auscultated Erb’s point with the bell
|
Exam Action |
|
Auscultated pulmonic area with the bell
|
Exam Action |
|
Auscultated aortic area with the bell
|
Exam Action |
|
Auscultated pulmonic area with the bell
|
Exam Action |
|
Auscultated Erb’s point with the bell
|
Exam Action |
|
Auscultated tricuspid area with the bell
|
Exam Action |
|
Auscultated tricuspid area with the diaphragm
|
Exam Action |
|
Auscultated mitral area with the diaphragm
|
Exam Action |
|
Auscultated mitral area with the bell
|
Exam Action |
|
Auscultated tricuspid area with the bell
|
Exam Action |
|
Auscultated Erb’s point with the bell
|
Exam Action |
|
Auscultated pulmonic area with the bell
|
Exam Action |
|
Auscultated aortic area with the bell
|
Exam Action |
|
Measured vitals
|
Exam Action |
|
Inspected right hand: no visible abnormal findings
|
Exam Action |
|
Inspected left hand: no visible abnormal findings
|
Exam Action |
|
Inspected left leg
|
Exam Action |
|
Inspected right leg
|
Exam Action |
|
Inspected toenails on left foot
|
Exam Action |
|
Inspected toenails on right foot
|
Exam Action |
|
Inspected right hand: no visible abnormal findings
|
Exam Action |
|
Inspected left hand: no visible abnormal findings
|
Exam Action |
|
Inspected fingernails of left hand
|
Exam Action |
|
Inspected fingernails of right hand
|
Exam Action |
|
Inspected fingernails of left hand
|
Exam Action |
|
Inspected fingernails of right hand
|
Exam Action |
|
Inspected right hand: no visible abnormal findings
|
Exam Action |
|
Inspected left hand: no visible abnormal findings
|
Exam Action |
|
Inspected left leg
|
Exam Action |
|
Inspected right leg
|
Exam Action |
|
Are you working ?
|
Question |
|
I work at a civil engineering firm here in town.
|
||
Do your sit a lot at work ? (Clarified to Do you sit down for long periods of time at work?.)
|
Question |
|
Well, yes, that’s the job. Unless I’m on site. [AUDIO COMING SOON] (Clarified to if I spend a lot of time sitting at work.)
|
||
What is the hours of working ?
|
Question |
|
I’m an engineer.
|
||
What is the working hours ?
|
Question |
|
My work life is pretty stable and generally low stress, I’d say.
|
||
It’s really good
|
Empathize |
|
EmpathizeSpeech
|
||
Do you like your job ?
|
Question |
|
Yeah, I like it. I’ve been there sixteen years.
|
||
It’s awesome
|
Empathize |
|
EmpathizeSpeech
|
||
Do you have a friends ?
|
Question |
|
Yep.
|
||
What type of social support do you have ? (No matching questions found.)
|
Question |
|
Where your socialize ?
|
Question |
|
My social life is mostly my family now. My wife and I are together all the time, and my son and his family lives in town. My daughter is in college so she’s home at least once a month. We try to have big family dinners when she’s home. I go fishing with my friend Smitty and his brother every once in a while.
|
||
How often do you go to fishing ? (Clarified to How often do you go to church?.)
|
Question |
|
I don’t usually go unless it’s on a holiday when my mother is in town. (Clarified to how often I go to church.)
|
||
How often do mother comes in town ?
|
Question |
|
I think I pee a normal amount. Every couple of hours or so.
|
Subjective Data Collection: 30 of 30 (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 chest pain
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.Example Question:
Do you have chest pain?
History of Present Illness
Finding:
Asked about onset of pain
Finding:
Reports chest pain started appearing in the past month
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
When did your chest pain start?
Finding:
Asked about location of pain
Finding:
Reports pain is in center of the chest
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Where is the pain?
Finding:
Reports pain does not radiate
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Does the pain radiate?
Finding:
Denies arm pain
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Are you experiencing arm pain?
Finding:
Denies shoulder pain
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Are you experiencing shoulder pain?
Finding:
Denies back pain
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Are you experiencing back pain?
Finding:
Denies neck pain
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Are you experiencing neck pain?
Finding:
Asked about duration of pain episodes
Finding:
Reports each pain episode lasted “several” minutes
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
How long does your chest pain last?
Finding:
Asked about frequency of pain
Finding:
Reports 3 pain episodes in past month
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
How many times in the last month have you had chest pain?
Finding:
Reports that pain episodes did not seem related
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Did the episodes seem associated?
Finding:
Asked about severity of pain
Finding:
Reports current pain is 0 out of 10
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
How would you rate your pain on a scale of zero to ten?
Finding:
Reports pain severity at its worst is 5 out of 10
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
How would you rate your pain on a scale of zero to ten?
Finding:
Asked about characteristics of pain
Finding:
Describes pain as tight and uncomfortable
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Can you describe your pain?
Finding:
Denies crushing pain
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Is the pain crushing?
Finding:
Denies gnawing pain
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Is the pain gnawing?
Finding:
Denies burning pain
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Is the pain burning?
Finding:
Asked about aggravating factors
Finding:
Reports pain is aggravated by activity
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
What makes the pain worse?
Finding:
Reports pain occurred with yard work and taking stairs
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
What activity triggered the pain?
Finding:
Reports pain does not worsen with eating
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Is the pain worse when you eat?
Finding:
Reports pain does not worsen after spicy foods
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Is the pain worse after you eat spicy food?
Finding:
Reports pain does not worsen after high-fat foods
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Is the pain worse after you eat high-fat foods?
Finding:
Asked about relieving factors
Finding:
Reports pain relief with brief period of rest
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
What relieves your pain?
Finding:
Denies taking medication to treat chest pain
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Did you take anything for the chest pain?
Past Medical History
Finding:
Confirmed allergies
Finding:
Confirms allergies
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Do you have new allergies?
Finding:
Asked about related medical conditions
Finding:
Denies angina diagnosis
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Do you have a history of angina?
Finding:
Reports high blood pressure
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Do you have high blood pressure?
Finding:
Reports high cholesterol
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Do you have high cholesterol?
Finding:
Denies coronary artery disease
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Do you have coronary artery disease?
Finding:
Denies diabetes
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Do you have diabetes?
Finding:
Denies previous treatment for chest pain
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Have you had previous treatment for chest pain?
Finding:
Asked about blood pressure monitoring
Finding:
Does not frequently monitor BP at home
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
How often do you measure your blood pressure?
Finding:
Reports infrequent BP checks
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
When do you measure your blood pressure?
Finding:
Denies knowledge of typical BP reading
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
What is your typical blood pressure reading?
Finding:
Asked about past cardiac tests
Finding:
Reports recent EKG test
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Have you recently had an EKG?
Finding:
Reports annual stress test
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Have you recently had a stress test?
Finding:
Followed up on results of cardiac tests
Finding:
Reports belief that EKG was normal
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
What were the results of your last EKG?
Finding:
Reports belief that stress test was normal
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
What were the results of your last stress test?
Home Medications
Finding:
Asked about home medications
Finding:
Reports taking high blood pressure medication
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
Do you take medication for high blood pressure?
Finding:
Reports taking high cholesterol medication
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
Do you take medication for high cholesterol?
Finding:
Reports occasional ibuprofen use
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
Do you take over the counter medications?
Finding:
Reports taking fish oil
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
Do you take any supplements?
Finding:
Denies aspirin regimen
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
Do you take aspirin?
Finding:
Followed up on high blood pressure medication
Finding:
Reports taking lisinopril
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
What medication do you take for high blood pressure?
Finding:
Reports lisinopril dose is 20 mg
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
What dose of medication do you take for high blood pressure?
Finding:
Reports taking lisinopril once daily
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
How frequently do you take medication for high blood pressure?
Finding:
Followed up on high cholesterol medication
Finding:
Reports taking atorvastatin
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
What medication do you take for high cholesterol?
Finding:
Reports atorvastatin dose is 20 mg
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
What dose of medication do you take for high cholesterol?
Finding:
Reports taking atorvastatin once daily
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
How frequently do you take medication for high cholesterol?
Finding:
Reports taking atorvastatin at bedtime
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
What time of day do you take your high cholesterol medication?
Finding:
Reports having taken atorvastatin for one year
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
How long have you taken cholesterol medication?
Social Determinants of Health
Finding:
Asked about access to healthcare
Finding:
Reports a primary care provider
(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:
Do you have a primary care provider?
Finding:
Reports last visit 3 months ago
(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:
When was your last visit to a healthcare provider?
Finding:
Reports usually sees healthcare provider every 6 months
(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:
How often do you see a healthcare provider?
Finding:
Denies transportation is a barrier to healthcare
(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:
Do you have difficulty accessing healthcare because of transportation?
Finding:
Denies finances are a barrier to healthcare
(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:
Do you have trouble affording healthcare?
Social History
Finding:
Asked about stress
Finding:
Reports generally low stress lifestyle
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
What is your stress level?
Finding:
Asked about exercise
Finding:
Denies regular exercise routine
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
What kind of exercise do you get?
Finding:
Reports last regular exercising was 2 years ago
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
When did you last exercise regularly?
Finding:
Asked about typical diet
Finding:
Reports typical breakfast is granola bar and instant breakfast shake
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
What is a typical breakfast for you?
Finding:
Reports typical lunch is turkey sub
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
What is a typical lunch for you?
Finding:
Reports typical dinner is grilled meat and vegetables
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
What is a typical dinner for you?
Finding:
Denies moderation of salt intake
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
Do you moderate your salt intake?
Finding:
Asked about fluid intake
Finding:
Reports drinking 4 glasses of water daily
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
Do you drink water every day?
Finding:
Reports drinking 2 cups of coffee daily
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
How much coffee do you drink per day?
Finding:
Denies soda drinking
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
How much soda do you drink per day?
Finding:
Asked about substance use
Finding:
Denies current illicit drug use
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
Do you use illicit drugs?
Finding:
Denies tobacco use
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
Do you use tobacco?
Finding:
Reports moderate alcohol consumption
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
Do you consume alcohol?
Finding:
Followed up on alcohol consumption
Finding:
Reports drinking 2-3 alcoholic drinks per week
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
Do you drink alcohol?
Finding:
Reports 2-3 drinks in one sitting
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
How many alcoholic drinks do you have in one sitting?
Finding:
Reports drinking only on weekends
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
When do you drink alcohol?
Review of Systems
Finding:
Asked about constitutional health
Finding:
Denies fever
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have a fever?
Finding:
Denies chills
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have chills?
Finding:
Denies fatigue
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you feel tired?
Finding:
Denies night sweats
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have night sweats?
Finding:
Denies weight loss
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you experienced recent weight loss?
Finding:
Denies dizziness or lightheadedness
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have dizziness?
Finding:
Denies palpitations
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have palpitations?
Finding:
Asked review of systems for cardiovascular
Finding:
Denies history of angina
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have a history of angina?
Finding:
Denies edema
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have any swelling?
Finding:
Denies circulation problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have any problems with circulation?
Finding:
Denies blood clots
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you ever had a blood clot?
Finding:
Denies history of rheumatic fever
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have a history of rheumatic fever?
Finding:
Denies history of heart murmur
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have a history of heart murmur?
Finding:
Denies easy bleeding
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you noticed any unusual bleeding?
Finding:
Denies easy bruising
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you noticed any unusual bruising?
Finding:
Denies blue skin
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Has your skin ever turned blue?
Finding:
Asked about review of systems for respiratory
Finding:
Denies cough
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have a cough?
Finding:
Denies difficulty breathing
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had difficulty breathing?
Finding:
Denies shortness of breath at rest
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have difficulty breathing when lying down?
Finding:
Asked about review of systems for HEENT
Finding:
Denies change in sense of taste
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you experienced a change in taste?
Finding:
Denies sore throat
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have a sore throat?
Finding:
Denies difficulty swallowing
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have dysphagia?
Finding:
Asked about review of systems for gastrointestinal
Finding:
Denies nausea
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have nausea?
Finding:
Denies vomiting
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you vomited recently?
Finding:
Denies diarrhea
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have diarrhea?
Finding:
Denies constipation
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have constipation?
Finding:
Denies gassiness
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you been gassy?
Finding:
Denies bloating
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have bloating?
Finding:
Denies heartburn or GERD
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have heartburn or GERD?
Family Medical History
Finding:
Asked about relevant family history
Finding:
Reports family history of heart attack
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Has anyone in your family had a heart attack?
Finding:
Denies family history of stroke
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Do you have a family history of stroke?
Finding:
Denies family history of pulmonary embolism
Objective Data Collection: 31 of 33 (93.94%)
- Correct
- Partially correct
- Incorrect
- Missed
- No visible abnormal findings
- Rash or lesion
- Cyanosis
- Pallor
- Redness or flushing
- Evidence of trauma (scar, laceration, or bruising)
- 4 cm or less above the sternal angle
- More than 4 cm above the sternal angle
- Symmetric
- Asymmetric
- 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)
- Symmetric
- Asymmetric
- Flat
- Rounded
- Protuberant
- Hollowed
- No visible abnormal findings
- Rash
- Striae
- Bulging around umbilicus
- Distension
- Visible masses (warts, cysts, or tumors)
- Freckles, birthmark, or discoloration
- Excessive hair growth
- Visible scars
- Laceration, lesion or wound
- Bruising
- 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
- No visible abnormal findings
- Pallor
- Cyanosis
- Splinter hemorrhages
- Clubbing
- 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
- No visible abnormal findings
- Pallor
- Cyanosis
- Splinter hemorrhages
- Clubbing
- No visible abnormal findings
- Visible distortion or swelling
- Brownish pigmentation
- Skin thickening
- Ulceration
- Varicose veins
- No visible abnormal findings
- Pallor
- Cyanosis
- Splinter hemorrhages
- Clubbing
- No visible abnormal findings
- Visible distortion or swelling
- Brownish pigmentation
- Skin thickening
- Ulceration
- Varicose veins
- No visible abnormal findings
- Pallor
- Cyanosis
- Splinter hemorrhages
- Clubbing
- No edema
- Pitting
- Non-pitting
- 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
- No edema
- Pitting
- Non-pitting
- 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
- Less than 3 seconds
- Greater than 3 seconds
- Less than 3 seconds
- Greater than 3 seconds
- No bruit
- Bruit
- No bruit
- Bruit
- S1 and S2 audible
- S1, S2, and S3 audible
- S1, S2, and S4 audible
- S1, S2, S3, and S4 audible
- No extra sounds
- Gallops
- Murmur
- Friction rub
- Valve clicks
- Present in all areas
- Diminished in some areas
- Absent in some areas
- No adventitious sounds
- Wheezing
- Fine crackles
- Stridor
- Rhonchi
- Course crackles
- 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
- No bruit
- Bruit
- No bruit
- Bruit
- No bruit
- Bruit
- No bruit
- Bruit
- No bruit
- Bruit
- No bruit
- Bruit
- No bruit
- Bruit
- Absent
- Hypoactive
- Normoactive
- Hyperactive
- All quadrants normoactive
- Right upper quadrant
- Right lower quadrant
- Left upper quadrant
- Left lower quadrant
- No thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- Present at midclavicular line and 5th intercostal space
- Displaced laterally
- Less than 3 cm
- Greater than 3 cm
- Brisk and tapping
- Increased amplitude (hyperkinetic)
- No thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- None reported
- Tenderness reported
- No quadrants tender
- Right upper quadrant
- Right lower quadrant
- Left upper quadrant
- Left lower quadrant
- No additional observations
- Masses
- Guarding
- Distension
- Muscle resistance
- Rigidity
- No palpable mass
- Palpable mass
- No palpable mass
- Right upper quadrant
- Right lower quadrant
- Left upper quadrant
- Left lower quadrant
- Around umbilicus
- Not palpable
- Palpable
- Not palpable
- Palpable
- Not palpable
- Palpable
- Not palpable
- Palpable
- No tenting
- Tenting
- No friction rub
- Audible friction rub
- No friction rub
- Audible friction rub
- All areas generally tympanic
- Some areas dull, some tympanic
- Some areas resonant
- Tympany
- Dullness
- Smaller than 6 cm
- Between 6 and 12 cm
- Greater than 12 cm
- Regular
- Irregular
- No ST elevation
- ST elevation present
Education & Empathy : 6 of 6 (100.0%)
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: Mr. Foster describes the symptoms that have been bothering him. |
||
What brought you here today ? |
Question |
|
I have been having some troubling chest pain in my chest now and then for the past month. |
||
Oh I’m sorry to hear that, it should be very uncomfortable to have that pain for a whole month. |
Empathize |
|
Thanks. I appreciate that. |
||
What is the onset of your pain ? |
Question |
|
I first noticed it earlier this month. I thought it might just be heartburn and it passed after about a couple of minutes. |
||
What is the exact location of the pain ? |
Question |
|
When the pain happens, I feel it mostly in the middle of my chest, over my heart. |
||
When did you chest pain start ? |
Question |
|
I first noticed it earlier this month. I thought it might just be heartburn and it passed after a couple of minutes. |
||
What is the exact location of the pain ? |
Question |
|
When the pain happens, I feel it mostly in the middle of my chest, over my heart. |
||
Sorry to hear that |
Empathize |
|
Thanks. I appreciate that. |
||
Easter pain radiates anywhere ? (Clarified to: Is your pain radiating?) |
Question |
|
The pain doesn’t radiate anywhere. It’s mostly just right in the middle of my chest. (Clarified to: if the pain is radiating) |
||
If your arm hurts (Clarified to: Do you have pain in your arm?) |
Question |
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No, when I am having the chest pain, it’s mostly just in middle of my chest. (Clarified to: if I have pain in my arm) |
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Do you have a pain in your shoulder ? |
Question |
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No, the pain hasn’t been in my shoulder. |
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Do you have a back pain ? |
Question |
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I haven’t had back pain, no. |
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Can you describe the duration of the pain ? (Clarified to: Can you tell me what the pain is like?) |
Question |
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Well, it mostly feels tight and uncomfortable right in the middle of my chest. (Clarified to: if I can tell you what the pain is like) |
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How often pain occurs ? (Clarified to: How often do you have pain?) |
Question |
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Well, it has happened three times the past month. It usually goes away after about a couple of minutes. (Clarified to: how often I have pain) |
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Can you describe your pain from 0 to 10 scale ? |
Question |
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I’d say maybe a . . . 5? It’s just really uncomfortable . . . like there’s nothing I can do about it. Right now it’s like a zero though. |
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Sorry to hear that |
Empathize |
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Thanks. I appreciate that. |
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Where else do you have a pain ? |
Question |
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No, when I am having the chest pain, it’s mostly just in middle of my chest. |
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Do you have a pain somewhere else in your body ? |
Question |
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No, when I am having the chest pain, it’s mostly just in middle of my chest. |
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What is the aggravating factors ? (Clarified to: Are there any aggravating factors?) |
Question |
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Well, the pain seems to start when I’m doing something physical . . . the first time it happened while I was doing yard work, and the second time . . . I had to take the stairs at work because the elevator broke. Both times it got better if I took a break or sat down to rest. (Clarified to: if there are aggravating factors) |
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What activity triggers pain ? |
Question |
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If I’m up and moving around I definitely notice it more and it makes me feel like I should sit down and take a deep breath or something. |
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He’s a pain worse when you eat ? |
Question |
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I don’t think eating has anything to do with it. One episode did happen when my wife and I were out for dinner, but it seemed to happen before we even settled. The episodes don’t seem all that related, to be honest. |
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It can be a lot of triggers in your diet which would aggravate and trigger your pain Mr.Foster. |
Educate |
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Good to know. Thank you. |
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Do you have stress ? |
Question |
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Not usually, but I’m feeling pretty anxious not knowing what’s going on with my chest. |
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I’m sorry to hear that |
Empathize |
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Thanks. I appreciate that. |
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What aggravates your pain ? |
Question |
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Well, I think it’s when I’m doing something physical most of the time. The first time it happened, my chest started hurting after I was doing some yard work. The second time happened when the elevator broke at work so I had to take the stairs. My office is on the 5th floor. |
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Do you like red meat ? |
Question |
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Yes, yes I do. |
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Do you like vegetables and fruits ? |
Educate |
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Good to know. Thank you. |
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You need to cut to read me like a beef pork and lamb because this meat is saturated with a bad cholesterol or fat. More than chicken and fish. Saturated and transfat can raise your blood cholesterol and make your heart disease worse. |
Educate |
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Good to know. Thank you. |
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You can replace the red meat by chicken or fish like a salmon which has a good cholesterol which which will help you to reduce your bad cholesterol and help you with your heart and cholesterol problems. |
Educate |
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Good to know. Thank you. |
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You need to start light exercising. |
Educate |
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Good to know. Thank you. |
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You need to include fresh vegetables and fruit in your diet. |
Educate |
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Good to know. Thank you. |
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You also need to continue taking your medications as prescribed. |
Educate |
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Good to know. Thank you. |
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You also need to wait yourself daily in the same clothes in the same time. |
Educate |
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Good to know. Thank you. |
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You need to do light exercise has three to four times a week. |
Educate |
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Good to know. Thank you. |
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Mister Foster you need to follow up with a primary care physician and a cardiologist. |
Educate |
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Good to know. Thank you. |
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You also need to eliminate you alcoholic beverages. |
Educate |
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Good to know. Thank you. |
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Model Statement: “I’m sorry you’re having these symptoms; chest pain can be uncomfortable and stressful. It’s good that you came in today so we can see what is causing your discomfort.” |
Description: Mr. Foster describes his past medical history of hypertension and high cholesterol. |
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When have you been diagnosed with hyperlipidemia ? (Clarified to: Are you diagnosed with high blood pressure?) |
Question |
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Yes, I supposedly have moderately high blood pressure. (Clarified to: if I have been diagnosed with hypertension) |
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I’m sorry to hear that |
Empathize |
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Thanks. I appreciate that. |
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She hasn’t been told that your cholesterol is always high ? |
Question |
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I’ve been told it’s moderately high. I’ve never noticed any actual symptoms from that though. |
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Have you been tested for diabetes ? |
Question |
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My mom and my sister both have diabetes, but I don’t have it. |
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Have you been monitoring your blood pressure ? |
Question |
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Not usually. They check it when I get checkups. My doctor has never seemed overly concerned about it. |
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Do you remember your last blood pressure reading ? (Clarified to: Do you know your blood pressure number?) |
Question |
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No, not offhand. (Clarified to: if I know my blood pressure number) |
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You need to monitor your blood pressure and you need to know your Baseline. |
Educate |
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Good to know. Thank you. |
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Model Statement: “It’s good that I know you have been diagnosed with hypertension and high cholesterol, because those conditions can cause additional heart problems. I would like to find out more about your diagnosis and treatment of those conditions.” |
Description: Mr. Foster reports that he does not exercise regularly. |
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Do you do exercise ? |
Question |
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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 if the doctor says it is OK to exercise with this chest pain I’ve been having. |
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I’m sorry to hear that your bike was stolen |
Empathize |
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Thanks. I appreciate that. |
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Do your exercise ? |
Question |
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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 if the doctor says it is OK to exercise with this chest pain I’ve been having. |
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I’m sorry that chest pain makes you not exercise |
Empathize |
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Thanks. I appreciate that. |
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Is it physical activity activates the pain ? |
Question |
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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 if the doctor says it is OK to exercise with this chest pain I’ve been having. |
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Sorry to hear that |
Empathize |
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Thanks. I appreciate that. |
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Model Statement: “Exercise is important for everyone, and particularly for people with high blood pressure and cholesterol. Let’s talk about some healthy forms of exercise that you would be interested in trying.” |
Description: Mr. Foster describes his dietary habits. |
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What type of food do you like ? |
Question |
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Um, let’s see . . . For breakfast I usually eat a granola bar and drink an instant breakfast shake. I’ve been doing that a while since it saves time in the morning. Most days for lunch I get a sandwich from the sub shop near work. That’s usually a turkey sub, but sometimes I get a spicy Italian sub. My wife and I grill a lot, and usually have some grilled meat with veggies for dinner. |
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United include a lot of processed and fast food which is not good for your body. To have the same fast food diet may affect you over the time. You need to change your diet. |
Educate |
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Good to know. Thank you. |
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You need to exercise.Not essential to do that with a bike. You can do sit ups, running or just simple indoor exercises in your home. |
Educate |
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Good to know. Thank you. |
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Model Statement: “Paying attention to your diet is a great start. It’s best to make sure you’re eating veggies, fruits, and whole grains, and lean proteins like fish or chicken.” |
Description: Mr. Foster reports weight gain of 15 to 20 pounds in the last few years. |
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Did you lose any weight? (Clarified to: Have you lost weight?) |
Question |
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Not exactly . . . I’ve gained about fifteen to twenty pounds in the last couple years. (Clarified to: if I have lost weight) |
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It’s not good to gain the weight. You need to change the diet and start doing the exercises. |
Educate |
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Good to know. Thank you. |
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Model Statement: “Gaining some weight over the years is very common. It’s a good idea to try to keep your weight in a healthy range. Things like moderate exercise and watching caloric intake can help keep you at a healthy weight.” |
Description: Mr. Foster has a family history of heart disease. |
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What’s what’s your fathers health ? |
Question |
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He really wasn’t doing so great in the last few years. He died when he was 75 of colon cancer, but even before that, his weight and his blood pressure and cholesterol were getting the best of him. It was rough. He didn’t last too long after the cancer diagnosis, unfortunately. I think he was tired of fighting. |
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I’m sorry to hear that it should be very difficult to lose the father |
Empathize |
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Thanks. I appreciate that. |
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How did you cope after you lost your father ? |
Question |
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Yeah. He died of colon cancer. He also had high blood pressure and high cholesterol. |
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Sorry to hear that |
Empathize |
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Thanks. I appreciate that. |
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Who’s your mother’s health ? |
Question |
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She has type 2 diabetes and some high blood pressure, but I think she’s doing pretty well for 80. |
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Do you have a brothers and sisters ? |
Question |
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I have a sister, and I had a brother but he died many years ago. |
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Sorry to hear that |
Empathize |
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Thanks. I appreciate that. |
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How was your maternal grandmother ? (Clarified to: How is the health of your maternal grandmother?) |
Question |
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She had breast cancer. She was in her 60s when she died. (Clarified to: how my maternal grandmother’s health is) |
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About maternal grandfather ? |
Question |
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My grandfather on my mom’s side died of a heart attack. He was in his mid-fifties. |
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Sorry to hear that |
Empathize |
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Thanks. I appreciate that. |
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How is your paternal grandfather ? |
Question |
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He was healthy right up until he died. He went in his sleep at 85, and we just called it old age. |
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Sorry to hear that |
Empathize |
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Thanks. I appreciate that. |
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Do you have any family history of heart attack ? |
Question |
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Well, my mom’s dad died of a heart attack. He was pretty young too. |
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Do you have a family history of a stroke ? |
Question |
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No, none that I know of. |
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Mr. Foster, Thank you for answering my questions now I’m going to do physical examination. |
Educate |
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Good to know. Thank you. |
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Thank you Mr. Foster. I’m done with physical evaluation |
Educate |
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Good to know. Thank you. |
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Mr.Foster how old are you ? |
Question |
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I’m 58 going on 30. |
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Early happy birthday |
Empathize |
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Thanks. I appreciate that. |
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Model Statement: “Thank you for sharing your family health information. It’s important that we know about any risk factors, so that you can make healthy choices to keep those risks low.” |
Documentation / Electronic Health Record
Document: Vitals
Vitals | |
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Blood Pressure | 146/90 |
O2 Sat | 98 |
Pulse | 104 |
Resp. Rate | 19 |
Temperature | 36.7 |
Documentation / Electronic Health Record
Document: Provider Notes
Student Documentation | Model Documentation |
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SubjectiveName Brian Foster. Patient is 58 y.o. male. Chief Complain : Chest Pain. Diagnosis: Stable angina pectoris. Mr. Foster notes that had that intermittent pain for a month located in mid-sternum. Patient describes the pain as heartburn which lasts only a couple of minutes and gives the sensation of the tightness in the chest. Patient mentioned that physical activity sometimes may aggravate the pain. He also notes that laying still helps to relieve the pain. Past Medical History: Mr. Foster denies any surgical history. Past medical history included hypertension diagnosed 1 year ago and hyperlipidemia diagnosed 1 year ago.. Family History: Patients father died at the age of 75 from colon CA. His PMH was high blood pressure, high cholesterol, obesity and colon CA. Mr Fosters mother is alive, she is 80 years old. Her PMH is Diabetes type 2, and high blood pressure. Patients brother is passed away at 24 y.o. from motorcycle accident. His sister is 52 years old. Her PMH is diabetes type 2 and high blood pressure… Mr Foster has a healthy 26 y.o. son, and daughter 19 years old. She has an asthma. Social History : Mr Foster denies tobacco and illicit drug use. He admits drinking 2-3 alcoholic drinks per week. General : Mr Foster notes gaining 15-20 lbs over the last couple of years. No complains of fatigue or muscle weakness noted. |
N/A |
ObjectiveBP 146/90, O2 Sat. 98% on RA, P 109, Respiratory Rate 19, Temp 36.7 orally Weight 197 lbs, Height 5.11, BMI 27.5 Patent is well appearing, friendly, well groomed with good maintained hygiene. No cognitive deficit noted. Patient is good historian in very pleasant mood. HEENT- pupils round, equal, brisk reactive to lights. All mucous membranes are moist. Neck- No pain in the neck or limited ROM noted. Respiratory-lungs clear, with mild crackles on posterior lower lungs. Abdominal- No Surgical scars or distention noted. Cardiac-Mild tachycardia 109 Skin is dry and warm. No tenting found. examination. Face- no abnormality symmetrical. Height of venous pressure 4 cm or less above the sternal angle. Chest is symmetrical. No visible and abnormal findings. Abdomen Symmetric No abnormal visible findings. Upper and lower extreemities- cyanosis noted. Negative to edema. Normal capillary refill, less than 3 seconds. Auscultated carotid arteries positive for bruit bilateral. Auscultated heart sounds present S1-S2 sounds audible. Gallops presentation noted. Auscultation of the breath sounds present in all areas, fine crackles and adventitious sounds present bilaterally in posterior upper lobe bilaterally. Auscultated abdominal aorta showing no bruit. Auscultated abdominal and lower extremity arteries negative for bruit in bilaterally in renal illiac and femoral arteries. No friction rub present upon auscultation of spleen and liver. Ausculcated bowel sounds are normoactive in all four quadrants. Palpitation of carotid arteries showing on the right side thrill with +3 increased amplitude. On the left side no thrill present with +2 expected amplitude. Palpated PMI displaced laterally. Brisk and tapping amplitude is less than 3 cm. Palpated Brachial arteries showing no thrill on the right side with amplitude +2 as expected. On the left side +2 expected amplitude. Palpated radial arteries presenting no thrill on the right side with +2 expected amplitude. On the left side there is no thrill as well with +2 expected amplitude. Palpated femoral arteries showing no thrill bilaterally with +2 expected amplitude. Palpation of popliteal, dorsalis pedis and tibial arteries indicated no thrill and +1 diminished or barely palpable amplitude bilaterally. Palpation of abdomen is normal no tenderness, mass or other abnormality present.Liver is palpable. Spleen is not palpable. Bilateral kidneys not palpable. Skin not tenting. Percussed abdomen showing that generally all abdominal quadrants as well as spleen are tympanic. Percussed liver size showing between 6and 12 cm. |
N/A |
AssessmentPatient is generally good looking, well appearing, maintains good hygiene. Good historian no cognitive deficit note. Alert oriented to person, place, time, situation. Neck: No pain, no restrictive movements or jugular vein distention noted. JVD is 3 cm above the sternal angle. A bruit is auscultated in the right carotid artery with positive thrill and amplitude of 3+No bruit found in the left carotid artery with no thrill and amplitude of 2+ Thorax: Maximum impulse found to be displaced laterally with brisk tapping and diameter of less than 3 cm. Respiratory: Lungs sounds are clear bilterally, anterior and posterior upper fields. Fine crackles heard bilaterally in posterior lower lung fields. Abdomen: Abdominal aorta free of bruits. No tenderness or massess noted on palpation. The liver is palpable. Spleen is not palpable. Right and left kidneys are not palpable. EKG performed and showed that patient has Normal Sinus Rhythm with no ST elevation. Periferall vascular : 1+tibial and DP pulses found bilaterally.1+popliteal pulses noted bilaterally with no thrill. 2+femoral and radial pulses noted bilaterally. Varicosites noted in bilateral lower extremities with minimal swelling and cyanosis. Mr Fosters chest pain related to his obesity and luck of exercise. He also consumes excessive amount red meat which may also can be related to high cholesterol condition. |
N/A |
PlanDiagnosis :Exertional chest pain relieved by rest. Stable Angina Pectoris. Diagnostics: Echocardiogram and stress test. Pharmacology: Continue current prescribed medications: Lopressor 100 mg PO Daily. Lipitor 20 mg PO Daily for high cholesterol Fish oil 1200 mg PO BID for managing heart disease. Start patient for new course of Nitroglycerin for chest pain episodes. Education/Counselling: Proper and routine monitoring weight, cardiac markers and lipid level. Patient will be instructed to change in diet and lifestyle includig the light exercise 3-4 times per week. Patient will be instructed to cut the red meat and include more chicken and fish in diet as well as more food with fiber such as fresh fruits, vegetables. Changes in diet and exercise will require for adjustment in medications. Referrals: Mr. Foster will be referred to cardiologist consultation for further evaluation. Patient will most likely required for further heart cathetherization with possible admission to the hospital with pre-procedure and post-procedure ECG monitoring and routine labwork. Follow up : Patient is to follow up with cardiologist within 2 days. To schedule the follow up appointment within 3-4 days. Mr. Foster were performed adequate and detailed health history and physical examination. The assessment was concentrated in Chief complain and rule out GI symptoms, which was not related in this particular case. His treatment plan reflects the current chief complain including objective and subjective result. |
N/ |
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