Cardiovascular | transcript.pdf - Cardiovascular | Completed | Shadow Health Cardiovascular Results | Turned In Advanced Health Assessment Chamberlain

Cardiovascular | transcript.pdf - Cardiovascular |...

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Unformatted text preview: 5/24/2018 Cardiovascular | Completed | Shadow Health Cardiovascular Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment Your Results Overview Lab Pass Transcript Transcript Subjective Data Collection Started: May 24, 2018 | Patient Exam Time: 121 min All Lines (207) Interview Questions (97) Statements (26) Exam Actions (84) Objective Data Collection Education & Empathy Hello my name is Sara student and I will be interviewing you today Documentation Lifespan Greet 05/24/18 2:27 PM CDT Hey. Review Questions Self-Reflection Please state your name. Question 05/24/18 2:28 PM CDT Tina Jones. What is your date of birth Question 05/24/18 2:28 PM CDT February 17th. How old are you? Question 05/24/18 2:28 PM CDT I'm 28. 1/24 5/24/2018 Cardiovascular | Completed | Shadow Health What brought you to the clinic today? Question 05/24/18 2:30 PM CDT I've been noticing my heart seems to be beating too fast every once in a while lately, and it started to worry me. My mom said I should make an appointment. You don't want to ignore heart stuff, I guess. I am sorry you're feeling bad. Empathize 05/24/18 2:32 PM CDT I appreciate you saying that. When did they start? (Clarified to when did this feeling start.) Question 05/24/18 2:35 PM CDT I think the first time was about a month ago. Describe what it feels like when your heart is beating fast? Question 05/24/18 2:35 PM CDT Well, when my heart starts beating really fast, it just feels like a thumping in my chest. It makes me anxious and uncomfortable. I'm sorry you feel like that Empathize 05/24/18 2:36 PM CDT Thanks. How often is your heart racing? Question 05/24/18 2:37 PM CDT It's been about once a week for the past month. How many episodes Have you had in the past month? (Clarified to How many times have you had palpitations?.) Question 05/24/18 2:38 PM CDT I guess three or four times. It's been about once a week for the past month. How long does your heart racing last? 2/24 5/24/2018 Cardiovascular | Completed | Shadow Health Question 05/24/18 2:39 PM CDT Not very long, maybe five to ten minutes max. Does the heart racing radiate? (Clarified to When does your heart beat faster.) Question 05/24/18 2:40 PM CDT I've only noticed them in the mornings, usually on the way to class. Maybe like once a week. What are you doing when this happens? Question 05/24/18 2:41 PM CDT I usually notice them on my way to class in the mornings. My schoolwork has really been picking up and I've been drinking energy drinks to help keep me focused during the day, so maybe the caffeine or whatever else is in those things has something to do with it. You know energy drinks are not good for your health Educate 05/24/18 2:41 PM CDT Alright, thanks for letting me know. And I understand you would like more energy but those drinks are not the way to go. Empathize 05/24/18 2:42 PM CDT Thanks for understanding. Can you describe what your heart racing feels like? Question 05/24/18 2:43 PM CDT Well, when my heart starts beating really fast, it just feels like a thumping in my chest. It makes me anxious and uncomfortable. Describe your anxious feeling when your heart is racing? (Clarified to what is anxiety like for you.) Question 05/24/18 2:44 PM CDT I guess when I'm stressed or anxious, I feel nervous. And I can feel overwhelmed. 3/24 5/24/2018 Cardiovascular | Completed | Shadow Health I'm sorry you feel like that we will try to help you Empathize 05/24/18 2:44 PM CDT I appreciate you telling me that. We can go over some exercises to help your anxiety Educate 05/24/18 2:45 PM CDT That makes sense. I will ask you some more questions to learn about your symptoms and will try to determine why you're feeling this way Educate 05/24/18 2:46 PM CDT Sure, I think I understand what you mean. When do you feel like your heart race? (Clarified to Is your heart racing right now? .) Question 05/24/18 2:46 PM CDT No, not right now. But that's what I've been feeling for the past month. What time of day does it feel like it starts to race? (No matching questions found.) Question 05/24/18 2:47 PM CDT Does your heart race in the morning? Question 05/24/18 2:47 PM CDT No, not right now. But that's what I've been feeling for the past month. Does exercise make your heart race? (Clarified to Does exertion aggravate the palpitations.) Question 05/24/18 2:47 PM CDT No, I haven't noticed anything like that. Does eating aggravate your palpitations? (Clarified to does eating anything worsen these palpitations.) Question 05/24/18 2:48 PM CDT No, not that I can tell. 4/24 5/24/2018 Cardiovascular | Completed | Shadow Health What relieves your heart racing? (Clarified to What activities make your heart race.) Question 05/24/18 2:48 PM CDT All I've been able to tell so far is that it happens in the mornings, usually as I'm getting ready or driving to school. I'm never doing anything out of the ordinary when it happens. What seems to relieve your palpitations? Question 05/24/18 2:50 PM CDT I try to slow down and breathe, and just relax. The feeling usually goes away after awhile. Good job that's a great exercise to help you calm down Educate 05/24/18 2:50 PM CDT OK, I understand. Do you take any medications for your palpitations? Question 05/24/18 2:50 PM CDT Yeah, I have my daily inhaler now, and I do that twice a day. I haven't had to use my rescue inhaler since I started using it. Does anything else make your palpitations go away (No matching questions found.) Question 05/24/18 2:51 PM CDT Are you taking any medication for your heart (Clarified to are you taking heart medicine.) Question 05/24/18 2:51 PM CDT I don't take any. Any history of high blood pressure? Question 05/24/18 2:52 PM CDT ...I've never been diagnosed with blood pressure problems. But I think it can be on the high side sometimes. Sorry to hear that Empathize 05/24/18 2:53 PM CDT Thanks for saying that. 5/24 5/24/2018 Cardiovascular | Completed | Shadow Health I did notice your blood pressure today was 145 over 90 on the high side Educate 05/24/18 2:53 PM CDT Thanks for telling me. Does high blood pressure run in your family? Question 05/24/18 2:53 PM CDT We've got high blood pressure in our family for sure. Granny, Mom, and Dad had it...and honestly I think my other three grandparents might've had issues with that, too. Having a history of high blood pressure in the family means that you could be at risk for developing high blood pressure to. Keeping blood pressure low is important to avoid any future health problems or health risk Educate 05/24/18 2:54 PM CDT OK, I understand. Also it is important when you are drinking energy drinks that have caffeine you need to drink more water then normal to stay hydrated Educate 05/24/18 2:55 PM CDT That makes sense. That much caffeine can dehydrate you increasing your water intake by double would help stay hydrated Educate 05/24/18 2:55 PM CDT Alright, thanks for letting me know. Do you exercise? Question 05/24/18 2:55 PM CDT I'm pretty exhausted by the end of the day, so I don't have the energy to do any extra exercise. But I'm on my feet all the time at work so I feel like that's a little bit of exercise most days at least. I understand you're busy. Empathize 05/24/18 2:56 PM CDT 6/24 5/24/2018 Cardiovascular | Completed | Shadow Health I appreciate you telling me that. Regular exercise is very important and can help relieve stress maybe taking a short walk every day may help reduce your anxiety and improve your health Educate 05/24/18 2:56 PM CDT Thanks for telling me. What medications do you take? Question 05/24/18 2:56 PM CDT I have a daily inhaler and a rescue inhaler for my asthma. Any new medication since your last visit? Question 05/24/18 2:57 PM CDT Yeah, I have a daily inhaler now that I've been using. What is the name of your daily inhaler? Question 05/24/18 2:57 PM CDT The daily inhaler is Flovent, and the rescue inhaler is Proventil. How much Proventil do you take? Question 05/24/18 2:57 PM CDT For the daily one, I do two puffs twice a day, like I'm supposed to. When was the last time you use your Proventil? Question 05/24/18 2:57 PM CDT I haven't needed my rescue inhaler for at least a month. Not since my last visit here. I think the daily inhaler you prescribed is really helping. When was the last time you had your blood pressure checked? Question 05/24/18 2:58 PM CDT The last time I was here in the clinic, the nurse checked it. 7/24 5/24/2018 Cardiovascular | Completed | Shadow Health It is important that you check your blood pressure when you can anytime a blood pressure cuff is available. Educate 05/24/18 2:59 PM CDT Sure, I think I understand what you mean. Do you have a heart murmur? Question 05/24/18 3:00 PM CDT No. Any swelling to your legs? Question 05/24/18 3:00 PM CDT No, not that I have noticed. Have you noticed any swelling in your arms? Question 05/24/18 3:00 PM CDT No. Have you noticed any swelling in your hands? Question 05/24/18 3:01 PM CDT No, not that I have noticed. Any shortness of breath? Question 05/24/18 3:01 PM CDT No, my breathing is fine right now. How is your stress level? Question 05/24/18 3:02 PM CDT It's not terrible, but I've definitely been more stressed than usual lately. School and work both just started getting really busy at the same time. What do you do at your job? 8/24 5/24/2018 Cardiovascular | Completed | Shadow Health Question 05/24/18 3:09 PM CDT Mid-American Copy & Ship is a good fit for me, especially while I work on my degree. They have been really understanding of my academic needs. Oh, and I get to do some accounting types of things when I take inventory or prepare orders. I'm glad they can help with your needs for school Empathize 05/24/18 3:10 PM CDT Thanks for understanding. Any changes in your diet? Question 05/24/18 3:10 PM CDT No, I'm a creature of habit. I eat the same foods all the time. How often do you use your flovent? Question 05/24/18 3:11 PM CDT I've been pretty good about using it every day. Prescribed dose of flovent? (No matching questions found.) Question 05/24/18 3:11 PM CDT dose of flovent? (No matching questions found.) Question 05/24/18 3:11 PM CDT What is the dose of your flovent? Question 05/24/18 3:12 PM CDT For the daily one, I do two puffs twice a day, like I'm supposed to. How many times a day do you use your flovent? Question 05/24/18 3:12 PM CDT Yeah, I have my daily inhaler now, and I do that twice a day. I haven't had to use my rescue inhaler since I started using it. 9/24 5/24/2018 Cardiovascular | Completed | Shadow Health Do you feel your flovent is effective (Clarified to How often do you use the Flovent inhaler.) Question 05/24/18 3:12 PM CDT I've been pretty good about using it every day. Describe your new inhaler? Question 05/24/18 3:13 PM CDT About a month ago, I was in here because my asthma was acting up, and the nurse practitioner prescribed me a daily inhaler. Any new allergies to report? Question 05/24/18 3:14 PM CDT No, not that I know of. Do you check your blood pressure on a regular basis? Question 05/24/18 3:15 PM CDT I almost never check it. I mean, maybe twice a year I might? It's not something I think about. It is important to check your blood pressure when you can Educate 05/24/18 3:15 PM CDT That makes sense. Are you aware of risk factors of hypertension (Clarified to are you aware of your risk for high blood pressure.) Question 05/24/18 3:15 PM CDT Yeah I guess I know, but I don't dwell on it. Do you have a history of heart disease? Question 05/24/18 3:16 PM CDT I've never been diagnosed with anything, no. Do you have a family history of heart disease? Question 05/24/18 3:16 PM CDT 10/24 5/24/2018 Cardiovascular | Completed | Shadow Health Um, none that I know of. Wait, my Poppa--that's Mom's dad--died of a heart attack. I'm sorry to hear that. Empathize 05/24/18 3:17 PM CDT I appreciate you saying that. Do you have a history of diabetes? Question 05/24/18 3:17 PM CDT Yeah, I was diagnosed a few years ago. Diagnosed with high cholesterol? (Clarified to do you have high cholesterol.) Question 05/24/18 3:17 PM CDT I've never had it tested. My family has problems with high cholesterol, but I don't think I do. Ever been diagnosed with rheumatic fever (No matching questions found.) Question 05/24/18 3:17 PM CDT diagnosed with rheumatic fever (No matching questions found.) Question 05/24/18 3:17 PM CDT any history of rheumatic fever Question 05/24/18 3:18 PM CDT No, I never got that as a kid. Have you ever had any heart test done? Question 05/24/18 3:19 PM CDT No, I've never had any problems with my heart before now. EKG? (No matching questions found.) Question 05/24/18 3:19 PM CDT Can you tell me what you eat daily? 11/24 5/24/2018 Cardiovascular | Completed | Shadow Health Question 05/24/18 3:19 PM CDT Let's see . . . a muffin or pumpkin bread for breakfast, a sandwich for lunch, and some kind of meat with a veggie for dinner. Do you eat snacks? Question 05/24/18 3:20 PM CDT Yeah, I usually have some snacks during the day. What type of snacks do you eat? Question 05/24/18 3:20 PM CDT I try to eat snacks that are kind of healthy like pretzels--sometimes if I'll treat myself and get french fries, but I try not to do that too often. Maybe try having some fruit or some veggies for snack instead of pretzels or fries Educate 05/24/18 3:21 PM CDT Sure, I think I understand what you mean. Have you increased your caffeine over the last month? (No matching questions found.) Question 05/24/18 3:21 PM CDT When did you increase your caffeine intake? (No matching questions found.) Question 05/24/18 3:21 PM CDT How often do you drink caffeine drinks Question 05/24/18 3:22 PM CDT Yeah, I've been drinking energy drinks a lot lately. I also drink Diet Coke. How often do you drink energy drinks? Question 05/24/18 3:22 PM CDT I've been having one every morning over the past month or so. A few times I've had two. Caffeine drinks are bad for you especially energy drinks try substituting one of those with water 12/24 5/24/2018 Cardiovascular | Completed | Shadow Health Educate 05/24/18 3:22 PM CDT Thanks for telling me. Why do you drink caffeine? (Clarified to do you drink caffeine.) Question 05/24/18 3:22 PM CDT Yeah, I've been drinking energy drinks a lot lately. I also drink Diet Coke. How does caffeine make you feel? (Clarified to What effect does caffeine have on you?.) Question 05/24/18 3:23 PM CDT I get kinda jittery. And now that we're talking about it, maybe it could be affecting my heart rate. You are correct that much caffeine could make your heart race. Educate 05/24/18 3:23 PM CDT OK, I understand. How is your energy level been? Question 05/24/18 3:24 PM CDT Most days I'm pretty exhausted by the end of the day--work really wipes me out, and if it's a week where I have a test or a paper, I'll be even more tired from all the studying. How was your activity level? Question 05/24/18 3:25 PM CDT I don't have the energy to do extra exercise after work. . . I'm pretty exhausted by the end of the day. But I'm moving around my whole shift at work, so that's something, at least. I completely understand. Empathize 05/24/18 3:25 PM CDT Thanks for saying that. Any recent respiratory illness 13/24 5/24/2018 Cardiovascular | Completed | Shadow Health Question 05/24/18 3:32 PM CDT No, I'm usually healthy. Any fever? Question 05/24/18 3:32 PM CDT No. Any nausea? Question 05/24/18 3:32 PM CDT No. Any vomiting? Question 05/24/18 3:33 PM CDT I don't even remember the last time I threw up--I don't think I have in years. Any chills? Question 05/24/18 3:33 PM CDT I haven't had chills, no. Low energy level? Question 05/24/18 3:33 PM CDT I feel like I have okay energy I guess...but most days I'm pretty exhausted by the end of the day. I understand I'm sorry to hear that Empathize 05/24/18 3:33 PM CDT Thanks. Any night sweats? Question 05/24/18 3:33 PM CDT 14/24 5/24/2018 Cardiovascular | Completed | Shadow Health I don't get sweaty, but sometimes I wake up hot and have to kick off my sheets. Are you having any chest pain? Question 05/24/18 3:36 PM CDT No, I've never had any chest pain. It doesn't hurt, it just feels like my heart is beating really fast. Chest tightness? Question 05/24/18 3:36 PM CDT Not really. Edema? (No matching questions found.) Question 05/24/18 3:36 PM CDT Any edema? Question 05/24/18 3:37 PM CDT No, not that I have noticed. Any circulation problems? Question 05/24/18 3:37 PM CDT I don't think I have any circulation problems. Any recent bleeding? (No matching questions found.) Question 05/24/18 3:37 PM CDT Do you bleed easily? Question 05/24/18 3:37 PM CDT I don't think so, no... I don't hurt myself very often. Any bruising? Question 05/24/18 3:37 PM CDT No, I don't think so. 15/24 5/24/2018 Cardiovascular | Completed | Shadow Health Any dizziness? Question 05/24/18 3:38 PM CDT No, I can't remember the last time I got dizzy. Any lightheadedness? Question 05/24/18 3:38 PM CDT I don't ever get light-headed. Any fainting? Question 05/24/18 3:38 PM CDT Um, not that I remember. Do you have any family history of heart disease? Question 05/24/18 3:39 PM CDT Um, none that I know of. Wait, my Poppa--that's Mom's dad--died of a heart attack. I'm sorry to hear that Empathize 05/24/18 3:40 PM CDT I appreciate you telling me that. When did he die of a heart attack (Clarified to how old was poppa when he passed.) Question 05/24/18 3:40 PM CDT Poppa died of a heart attack when he was 80. . . he had some blood pressure and cholesterol issues when he was alive, too. Any family history of coronary artery disease? Question 05/24/18 3:41 PM CDT No, I don't think so. Any family history of high cholesterol? Question 05/24/18 3:41 PM CDT 16/24 5/24/2018 Cardiovascular | Completed | Shadow Health Cholesterol runs high in my family. All four of my grandparents have high cholesterol, and Mom and Dad, too. Any family history of hypertension? Question 05/24/18 3:41 PM CDT We've got high blood pressure in our family for sure. Granny, Mom, and Dad had it...and honestly I think my other three grandparents might've had issues with that, too. Any family history of heart attack Question 05/24/18 3:42 PM CDT Um, none that I know of. Wait, my Poppa--that's Mom's dad--died of a heart attack. Any family history of a stroke? Question 05/24/18 3:42 PM CDT Yeah, that's how my Nana died. At what age did your nana die? Question 05/24/18 3:42 PM CDT Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too. I am sorry to hear about that. Empathize 05/24/18 3:43 PM CDT Thanks for understanding. Any family history of obesity? Question 05/24/18 3:43 PM CDT No, I don't think so. My brother and my dad are kind of big, but I wouldn't say they were obese or anything. Inspected anterior chest wall Exam Action 05/24/18 4:00 PM CDT Inspected left side chest wall 17/24 5/24/2018 Cardiovascular | Completed | Shadow Health Exam Action 05/24/18 4:01 PM CDT Inspected posterior chest wall Exam Action 05/24/18 4:01 PM CDT Inspected right side chest wall Exam Action 05/24/18 4:01 PM CDT Inspected anterior chest wall Exam Action 05/24/18 4:01 PM CDT Inspected for jugular venous distention: JVP 1 cm above sternal angle Exam Action 05/24/18 4:01 PM CDT Inspected fingernails of left hand Exam Action 05/24/18 4:02 PM CDT Inspected fingernails of right hand Exam Action 05/24/18 4:02 PM CDT Checked capillary refill in fingernails Exam Action 05/24/18 4:02 PM CDT Checked capillary refill in fingernails Exam Action 05/24/18 4:02 PM CDT Checked capillary refill in fingernails Exam Action 05/24/18 4:02 PM CDT Checked capillary refill in fingernails Exam Action 05/24/18 4:03 PM CDT Checked capillary refill in fingernails Exam Action 05/24/18 4:03 PM CDT Checked capillary refill in fingernails Exam Action 05/24/18 4:03 PM CDT 18/24 5/24/2018 Cardiovascular | Completed | Shadow Health Checked capillary refill in fingernails Exam Action 05/24/18 4:03 PM CDT Checked capillary refill in fingernails Exam Action 05/24/18 4:03 PM CDT Inspected...
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