Blog

• 
  

  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?

• 
  

  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?

• 
  

  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?

• 
  

  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?

• 
  

  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?

• 
  

  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?

• 
  

  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?

• 
  

  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

 Inspected face

1 of 1 point

Appearance (1/1 point)

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

 Inspected for jugular venous distension

1 of 1 point

Height Of Venous Pressure (1/1 point)

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

 Inspected chest

1 of 1 point

Symmetry (1/2 point)

•  Symmetric
•  Asymmetric

Appearance (1/2 point)

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

 Inspected abdomen

1 of 1 point

Symmetry (1/3 point)

•  Symmetric
•  Asymmetric

Contour (1/3 point)

•  Flat
•  Rounded
•  Protuberant
•  Hollowed

Appearance (1/3 point)

•  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

 Inspected hands and fingernails

0.5 of 1 point

Right: Appearance (1/4 point)

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

Right: Nail Changes (No point)

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

Left: Appearance (1/4 point)

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

Left: Nail Changes (No point)

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

 Inspected lower extremities and toenails

0.5 of 1 point

Right: Appearance (1/4 point)

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

Right: Nail Changes (No point)

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

Left: Appearance (1/4 point)

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

Left: Nail Changes (No point)

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

 Inspect lower extremities for edema

1 of 1 point

Right: Edema (1/4 point)

•  No edema
•  Pitting
•  Non-pitting

Right: Severity Of Edema (1/4 point)

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

Left: Edema (1/4 point)

•  No edema
•  Pitting
•  Non-pitting

Left: Severity Of Edema (1/4 point)

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

 Tested capillary refill time

1 of 1 point

Fingers (1/2 point)

•  Less than 3 seconds
•  Greater than 3 seconds

Toes (1/2 point)

•  Less than 3 seconds
•  Greater than 3 seconds

 Auscultated carotid arteries

0.5 of 1 point

Right (1/2 point)

•  No bruit
•  Bruit

Left (No point)

•  No bruit
•  Bruit

 Auscultated heart sounds

0.5 of 1 point

Heart Sounds (No point)

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

Extra Heart Sounds (1/2 point)

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

 Auscultated breath sounds

1 of 1 point

Breath Sounds (1/3 point)

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

Adventitious Sounds (1/3 point)

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

Location (1/3 point)

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

 Auscultated abdominal aorta

1 of 1 point 

Sounds (1/1 point)

•  No bruit
•  Bruit

 Auscultated abdominal and lower extremity arteries

1 of 1 point

Right: Renal (1/6 point)

•  No bruit
•  Bruit

Left: Renal (1/6 point)

•  No bruit
•  Bruit

Right: Iliac (1/6 point)

•  No bruit
•  Bruit

Left: Iliac (1/6 point)

•  No bruit
•  Bruit

Right: Femoral (1/6 point)

•  No bruit
•  Bruit

Left: Femoral (1/6 point)

•  No bruit
•  Bruit

 Auscultated bowel sounds

1 of 1 point

Bowel Sounds (1/2 point)

•  Absent
•  Hypoactive
•  Normoactive
•  Hyperactive

Location Of Non Normoactive Bowel Sounds (1/2 point)

•  All quadrants normoactive
•  Right upper quadrant
•  Right lower quadrant
•  Left upper quadrant
•  Left lower quadrant

 Palpated carotid arteries

1 of 1 point

Right: Vibration (1/4 point)

•  No thrill
•  Thrill

Right: Amplitude (1/4 point)

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

Left: Vibration (1/4 point)

•  No thrill
•  Thrill

Left: Amplitude (1/4 point)

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

 Palpated PMI

1 of 1 point

Location (1/3 point)

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

Diameter (1/3 point)

•  Less than 3 cm
•  Greater than 3 cm

Amplitude (1/3 point)

•  Brisk and tapping
•  Increased amplitude (hyperkinetic)

 Palpated brachial arteries

1 of 1 point

Right: Vibration (1/4 point)

•  No thrill
•  Thrill

Right: Amplitude (1/4 point)

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

Left: Vibration (1/4 point)

•  No thrill
•  Thrill

Left: Amplitude (1/4 point)

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

 Palpated radial arteries

1 of 1 point

Right: Vibration (1/4 point)

•  No thrill
•  Thrill

Right: Amplitude (1/4 point) 

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

Left: Vibration (1/4 point)

•  No thrill
•  Thrill

Left: Amplitude (1/4 point)

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

 Palpated femoral arteries

1 of 1 point

Right: Vibration (1/4 point)

•  No thrill
•  Thrill

Right: Amplitude (1/4 point)

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

Left: Vibration (1/4 point)

•  No thrill
•  Thrill

Left: Amplitude (1/4 point)

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

 Palpated popliteal arteries

1 of 1 point

Right: Vibration (1/4 point)

•  No thrill
•  Thrill

Right: Amplitude (1/4 point)

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

Left: Vibration (1/4 point)

•  No thrill
•  Thrill

Left: Amplitude (1/4 point)

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

 Palpated tibial arteries

1 of 1 point

Right: Vibration (1/4 point)

•  No thrill
•  Thrill

Right: Amplitude (1/4 point)

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

Left: Vibration (1/4 point)

•  No thrill
•  Thrill

Left: Amplitude (1/4 point)

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

 Palpated dorsalis pedis arteries

1 of 1 point

Right: Vibration (1/4 point)

•  No thrill
•  Thrill

Right: Amplitude (1/4 point)

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

Left: Vibration (1/4 point)

•  No thrill
•  Thrill

Left: Amplitude (1/4 point)

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

 Palpated abdomen – light

1 of 1 point

Tenderness (1/3 point)

•  None reported
•  Tenderness reported

Location Of Tenderness (1/3 point)

•  No quadrants tender
•  Right upper quadrant
•  Right lower quadrant
•  Left upper quadrant
•  Left lower quadrant

Observations (1/3 point)

•  No additional observations
•  Masses
•  Guarding
•  Distension
•  Muscle resistance
•  Rigidity

 Palpated abdomen – deep

1 of 1 point

Presence Of Unexpected Mass (1/2 point)

•  No palpable mass
•  Palpable mass

Location Of Mass (1/2 point)

•  No palpable mass
•  Right upper quadrant
•  Right lower quadrant
•  Left upper quadrant
•  Left lower quadrant
•  Around umbilicus

 Palpated liver

1 of 1 point

Detection (1/1 point)

•  Not palpable
•  Palpable

 Palpated spleen

1 of 1 point

Detection (1/1 point)

•  Not palpable
•  Palpable

 Palpated kidneys

1 of 1 point

Right (1/2 point)

•  Not palpable
•  Palpable

Left (1/2 point)

•  Not palpable
•  Palpable

 Tested skin turgor

1 of 1 point

Observations (1/1 point)

•  No tenting
•  Tenting

 Auscultated organs

1 of 1 point

Liver (1/2 point)

•  No friction rub
•  Audible friction rub

Spleen (1/2 point) 

•  No friction rub
•  Audible friction rub

 Percussed abdomen

1 of 1 point

Observations (1/1 point)

•  All areas generally tympanic
•  Some areas dull, some tympanic
•  Some areas resonant

 Percussed spleen

1 of 1 point

Spleen (1/1 point)

•  Tympany
•  Dullness

 Percussed liver

1 of 1 point

Liver Span (1/1 point)

•  Smaller than 6 cm
•  Between 6 and 12 cm
•  Greater than 12 cm

 Performed EKG

1 of 1 point

Sinus Rhythm (1/2 point)

•  Regular
•  Irregular

St Changes (1/2 point)

•  No ST elevation
•  ST elevation present

Education & Empathy : 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

 1 Symptoms

Followed Up

	Description: Mr. Foster describes the symptoms that have been bothering him.
	What brought you here today ?	Question 01:18 PM MDT
	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 01:22 PM MDT
	Thanks. I appreciate that.
	What is the onset of your pain ?	Question 01:23 PM MDT
	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 01:24 PM MDT
	When the pain happens, I feel it mostly in the middle of my chest, over my heart.
	When did you chest pain start ?	Question 01:25 PM MDT
	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 01:25 PM MDT
	When the pain happens, I feel it mostly in the middle of my chest, over my heart.
	Sorry to hear that	Empathize 01:26 PM MDT
	Thanks. I appreciate that.
	Easter pain radiates anywhere ? (Clarified to: Is your pain radiating?)	Question 01:26 PM MDT
	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 01:26 PM MDT
	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)
	Do you have a pain in your shoulder ?	Question 01:27 PM MDT
	No, the pain hasn’t been in my shoulder.
	Do you have a back pain ?	Question 01:27 PM MDT
	I haven’t had back pain, no.
	Can you describe the duration of the pain ? (Clarified to: Can you tell me what the pain is like?)	Question 01:28 PM MDT
	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)
	How often pain occurs ? (Clarified to: How often do you have pain?)	Question 01:29 PM MDT
	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)
	Can you describe your pain from 0 to 10 scale ?	Question 01:29 PM MDT
	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.
	Sorry to hear that	Empathize 01:30 PM MDT
	Thanks. I appreciate that.
	Where else do you have a pain ?	Question 02:36 PM MDT
	No, when I am having the chest pain, it’s mostly just in middle of my chest.
	Do you have a pain somewhere else in your body ?	Question 02:37 PM MDT
	No, when I am having the chest pain, it’s mostly just in middle of my chest.
	What is the aggravating factors ? (Clarified to: Are there any aggravating factors?)	Question 02:37 PM MDT
	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)
	What activity triggers pain ?	Question 02:39 PM MDT
	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.
	He’s a pain worse when you eat ?	Question 02:40 PM MDT
	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.
	It can be a lot of triggers in your diet which would aggravate and trigger your pain Mr.Foster.	Educate 02:43 PM MDT
	Good to know. Thank you.
	Do you have stress ?	Question 06:36 AM MDT
	Not usually, but I’m feeling pretty anxious not knowing what’s going on with my chest.
	I’m sorry to hear that	Empathize 06:36 AM MDT
	Thanks. I appreciate that.
	What aggravates your pain ?	Question 04:54 AM MDT
	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 05:59 AM MDT
	Yes, yes I do.
	Do you like vegetables and fruits ?	Educate 05:59 AM MDT
	Good to know. Thank you.
	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 06:05 AM MDT
	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 06:07 AM MDT
	Good to know. Thank you.
	You need to start light exercising.	Educate 06:07 AM MDT
	Good to know. Thank you.
	You need to include fresh vegetables and fruit in your diet.	Educate 06:08 AM MDT
	Good to know. Thank you.
	You also need to continue taking your medications as prescribed.	Educate 06:08 AM MDT
	Good to know. Thank you.
	You also need to wait yourself daily in the same clothes in the same time.	Educate 06:09 AM MDT
	Good to know. Thank you.
	You need to do light exercise has three to four times a week.	Educate 06:09 AM MDT
	Good to know. Thank you.
	Mister Foster you need to follow up with a primary care physician and a cardiologist.	Educate 06:10 AM MDT
	Good to know. Thank you.
	You also need to eliminate you alcoholic beverages.	Educate 06:11 AM MDT
	Good to know. Thank you.
	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.”

 2 Hypertension and High Cholesterol

Followed Up

	Description: Mr. Foster describes his past medical history of hypertension and high cholesterol.
	When have you been diagnosed with hyperlipidemia ? (Clarified to: Are you diagnosed with high blood pressure?)	Question 02:52 PM MDT
	Yes, I supposedly have moderately high blood pressure. (Clarified to: if I have been diagnosed with hypertension)
	I’m sorry to hear that	Empathize 02:52 PM MDT
	Thanks. I appreciate that.
	She hasn’t been told that your cholesterol is always high ?	Question 06:29 AM MDT
	I’ve been told it’s moderately high. I’ve never noticed any actual symptoms from that though.
	Have you been tested for diabetes ?	Question 06:29 AM MDT
	My mom and my sister both have diabetes, but I don’t have it.
	Have you been monitoring your blood pressure ?	Question 06:29 AM MDT
	Not usually. They check it when I get checkups. My doctor has never seemed overly concerned about it.
	Do you remember your last blood pressure reading ? (Clarified to: Do you know your blood pressure number?)	Question 06:30 AM MDT
	No, not offhand. (Clarified to: if I know my blood pressure number)
	You need to monitor your blood pressure and you need to know your Baseline.	Educate 06:30 AM MDT
	Good to know. Thank you.
	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.”

 3 Exercise

Followed Up

	Description: Mr. Foster reports that he does not exercise regularly.
	Do you do exercise ?	Question 02:53 PM MDT
	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.
	I’m sorry to hear that your bike was stolen	Empathize 02:53 PM MDT
	Thanks. I appreciate that.
	Do your exercise ?	Question 06:37 AM MDT
	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.
	I’m sorry that chest pain makes you not exercise	Empathize 06:37 AM MDT
	Thanks. I appreciate that.
	Is it physical activity activates the pain ?	Question 04:53 AM MDT
	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 04:53 AM MDT
	Thanks. I appreciate that.
	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.”

 4 Diet

Followed Up

	Description: Mr. Foster describes his dietary habits.
	What type of food do you like ?	Question 02:54 PM MDT
	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.
	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 02:57 PM MDT
	Good to know. Thank you.
	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 02:59 PM MDT
	Good to know. Thank you.
	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.”

 5 Weight Gain

Followed Up

	Description: Mr. Foster reports weight gain of 15 to 20 pounds in the last few years.
	Did you lose any weight? (Clarified to: Have you lost weight?)	Question 02:59 PM MDT
	Not exactly . . . I’ve gained about fifteen to twenty pounds in the last couple years. (Clarified to: if I have lost weight)
	It’s not good to gain the weight. You need to change the diet and start doing the exercises.	Educate 03:10 PM MDT
	Good to know. Thank you.
	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.”

 6 Family History

Followed Up

	Description: Mr. Foster has a family history of heart disease.
	What’s what’s your fathers health ?	Question 03:14 PM MDT
	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.
	I’m sorry to hear that it should be very difficult to lose the father	Empathize 03:15 PM MDT
	Thanks. I appreciate that.
	How did you cope after you lost your father ?	Question 03:16 PM MDT
	Yeah. He died of colon cancer. He also had high blood pressure and high cholesterol.
	Sorry to hear that	Empathize 03:16 PM MDT
	Thanks. I appreciate that.
	Who’s your mother’s health ?	Question 03:16 PM MDT
	She has type 2 diabetes and some high blood pressure, but I think she’s doing pretty well for 80.
	Do you have a brothers and sisters ?	Question 03:17 PM MDT
	I have a sister, and I had a brother but he died many years ago.
	Sorry to hear that	Empathize 03:17 PM MDT
	Thanks. I appreciate that.
	How was your maternal grandmother ? (Clarified to: How is the health of your maternal grandmother?)	Question 03:17 PM MDT
	She had breast cancer. She was in her 60s when she died. (Clarified to: how my maternal grandmother’s health is)
	About maternal grandfather ?	Question 03:18 PM MDT
	My grandfather on my mom’s side died of a heart attack. He was in his mid-fifties.
	Sorry to hear that	Empathize 03:18 PM MDT
	Thanks. I appreciate that.
	How is your paternal grandfather ?	Question 03:18 PM MDT
	He was healthy right up until he died. He went in his sleep at 85, and we just called it old age.
	Sorry to hear that	Empathize 03:19 PM MDT
	Thanks. I appreciate that.
	Do you have any family history of heart attack ?	Question 06:46 AM MDT
	Well, my mom’s dad died of a heart attack. He was pretty young too.
	Do you have a family history of a stroke ?	Question 06:47 AM MDT
	No, none that I know of.
	Mr. Foster, Thank you for answering my questions now I’m going to do physical examination.	Educate 06:49 AM MDT
	Good to know. Thank you.
	Thank you Mr. Foster. I’m done with physical evaluation	Educate 07:30 AM MDT
	Good to know. Thank you.
	Mr.Foster how old are you ?	Question 04:13 AM MDT
	I’m 58 going on 30.
	Early happy birthday	Empathize 04:14 AM MDT
	Thanks. I appreciate that.
	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
• Document: Provider Notes

Document: Vitals

Vitals
Blood Pressure	146/90
O2 Sat	98
Pulse	104
Resp. Rate	19
Temperature	36.7

Documentation / Electronic Health Record

• Document: Vitals
• Document: Provider Notes

Document: Provider Notes

Student Documentation	Model Documentation
Subjective Name 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
Objective BP 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
Assessment Patient 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
Plan Diagnosis :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 inclusing objective and subjective result.	N/