with a specifi c event, but notes that they usually occur about once per week in the morning on her commute to class. The episodes generally last between 5 and 10 minutes and resolve spontaneously. She denies chest pain during the

episodes.

Timeframe: 4 months after establishing primary care (Age: 28) Reason for visit: Patient presents complaining of recent episodes of fast heartbeat.

Module 4 - Cardiovascular

Develop strong communication skills � Interview the patient to elicit subjective health information about her health and health history

� Ask relevant follow-up questions to evaluate patient condition � Demonstrate empathy for patient perspectives, feelings, and sociocultural background � Identify opportunities to educate the patient

Document accurately and appropriately � Document subjective data using professional terminology

� Organize appropriate documentation in the EHR

Demonstrate clinical reasoning skills � Organize all components of an interview

� Assess risk for disease, infection, injury, and complications

After completing the assessment, you will refl ect on personal strengths, limitations, beliefs, prejudices, and values.

Learning Objectives

I’ve noticed my heart has been beating faster than usual lately, and I thought it was something I should get checked out.“

R00.2, Palpitations

Underlying ICD- 10 Diagnoses

� Student Performance Index - This style of rubric contains subjective and objective data categories. Subjective

data categories include interview questions and patient data. Objective data categories include examination and patient data.

Module Features

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Cardiovascular - TINA JONES™ ADVANCED HEALTH ASSESSMENT

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Ms. Jones is a pleasant 28- year- old African American woman who presented to the clinic with complaints of 3 -4 episodes of rapid heart rate over the last month. She is a good historian. She describes these episodes as “thumping in her chest” with a heart rate that is “way faster than usual”. She does not associate the rapid heart rate with a specifi c event, but notes that they usually occur about once per week in the morning on her commute to class. The episodes generally last between 5 and 10 minutes and resolve spontaneously. She does not know her normal heart rate or her heart rate during these episodes. She denies chest pain during the episodes, but does endorse discomfort of 3/10 which she attributes to associated anxiety regarding her rapid heart rate. She denies shortness of breath. She denies any association of symptoms with exertion. She has no known cardiac history and has never had episodes prior to this last month. She has not attempted any treatment at home and states that she is only coming to the clinic today because her family has expressed concern regarding these episodes.

History of Present Illness

Medications

1. Fluticasone propionate, 110 mcg 2 puff s BID (last use: this morning)

2. Albuterol 90 mcg/spray MDI 2 puff s Q4H prn (last

use: “a month ago”) 3. Acetaminophen 500- 1000 mg PO prn (headaches) 4. Ibuprofen 600 mg PO TID prn (cramps)

Vitals

� Weight (kg) - 87 � BMI - 30.1 � Heart Rate (HR) - 90 � Respiratory Rate (RR) - 16

� Pulse Oximetry - 99% � Blood Pressure (BP) - 145/90 � Blood Glucose - 140 � Temperature (F) - 98.9

� General: Denies changes in weight, but complains of end of day fatigue. She denies fevers, chills, and night sweats. She complains of intermittent dizziness.

� Cardiac: Denies a diagnosis of hypertension, but states that she has been told her blood pressure was high in the past. She checks it at CVS periodically. At last check it was “140/80 or 90”. She denies known history of murmurs, angina, previous palpitations, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or edema. She has never had an EKG.

� Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16 for asthma, last chest XR was age 16

� Hematologic: She denies a history of anemia, easy bruising or bleeding, petechiae, purpura, or blood transfusions.

Review of Systems

Printable “Answer Key” available within the Shadow Health DCE.

Subjective and Objective Model Documentation

� Symptoms - Fast heartbeat � Diagnosis - Palpitations

Chief Complaint

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Cardiovascular - TINA JONES™ ADVANCED HEALTH ASSESSMENT

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Abnormal Findings

Subjective (Reported by Tina) � Experienced 3-4 episodes of fast heartbeat and a

“thumping feeling” in the last month � Episodes accompanied by mild anxiety � Increased stress related to work and school � Increased caff eine consumption from diet soda and

energy drinks � Risk factors for cardiovascular disease: type 2

diabetes, sedentary lifestyle and family history of high cholesterol and hypertension

Objective (Found by the student performing physical exam) � Heart rate in the clinic is not tachycardic: 90 bpm � Hypertensive blood pressure reading: 145 / 90 � Risk factor for cardiovascular disease: Obesity (BSM

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Assessment

Palpitations related to caff eine and/or anxiety

Plan

1. Encourage Ms. Jones to continue to monitor symptoms and log her episodes of palpitations with associated factors and bring log to next visit.

2. Obtain EKG to rule out any cardiac abnormality and assess for symptom correlated EKG changes. If inconclusive, consider ambulatory EKG monitoring and referral to Cardiologist

3. Encourage to decrease caff eine consumption and increase intake of water and other fl uids. 4. Educate on anxiety reduction strategies including deep breathing, relaxation, and guided imagery. Continue to

monitor and explore the need for possible referral to social work/psychiatry or pharmacologic intervention. 5. Discuss the need to maintain a stable blood pressure. Encourage Ms. Jones to continue to monitor her blood

pressure when a cuff or machine is available. 6. Educate Ms. Jones on when to seek emergent care including episodes of chest pain unrelieved by rest,

palpitations that do not dissipate after anxiety related strategies were implemented, changes in vision, loss of consciousness, and sense of impending doom.

7. Revisit clinic in 2 4 weeks for follow up and evaluation.

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