Cardiovascular Tina Jones Shadow Health Transcript
Transcript
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Hello my name is Danielle I will be your provider today
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Hey.
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Can you verify your name
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Tina Jones.
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Your date of birth
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February 17th.
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Thank you
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You’re welcome.
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What brings you in today
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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.
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I’m sorry to hear you’re experiencing those symptoms, they can be very uncomfortable. I’ll ask you some questions to learn more about your symptoms, and we will try to determine what’s causing you to feel this way
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Thanks for saying that.
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When did you first notice these symptoms
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I think the first time was about a month ago.
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What were you doing when you noticed these symptoms (Clarified to What were you doing when you got the palpitations?.)
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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. (Clarified to what I was doing when the palpitations occured.)
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How many energy drinks do you drink per day
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Usually just one in the morning, kind of like some people have a cup of coffee. Some mornings lately I’ve had two, though.
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Drinking high levels of caffeine can make you feel stressed or anxious, and can dehydrate you. over time, lots of caffeine can make you experience “crashes” during the day, too. let’s talk about healthy alternatives
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Sure, I think I understand what you mean.
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How often were you experiencing these symptoms
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No.
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How often do you notice your heart racing fast (Clarified to How often does your heart beat fast?.)
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It’s been about once a week for the past month. (Clarified to how often my heart beats fast.)
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Can you describe it for me (Clarified to What is your heartbeat like?.)
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It’s usually normal, but it’s way faster during these episodes I’ve been having. (Clarified to what my heartbeat is like.)
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How do you feel when your heart is racing fast
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Well, when my heart starts beating really fast, it just feels like a thumping in my chest. It makes me anxious and uncomfortable.
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Is there anything that relieves the fast heartbeat (Clarified to Does anything relieve your symptoms?.)
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I haven’t tried anything specific, other than just trying to relax and breathe deep. (Clarified to if anything relieves my symptoms.)
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Do you take any medications to help you with your symptoms
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Nope.
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What medications are you taking
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I have a daily inhaler and a rescue inhaler for my asthma.
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Are you taking any new medications
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Yeah, I have a daily inhaler now that I’ve been using.
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What’s the name of the medication
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The daily inhaler is Flovent, and the rescue inhaler is Proventil.
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Do you have any new allergies
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No, not that I know of.
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Do you have a history of hypertension
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…I’ve never been diagnosed with blood pressure problems. But I think it can be on the high side sometimes.
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Do you check your blood pressure
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Only when I’m here at the clinic.
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Do you have any health history that would contribute to hypertension (No matching questions found.)
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Do you have diabetes
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Yeah, I was diagnosed a few years ago.
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Do you have high cholesterol
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I’ve never had it tested. My family has problems with high cholesterol, but I don’t think I do.
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Any history of a heart murmur
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No.
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Do you have health insurance
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I have health insurance through work. To be honest, though, I’m not exactly sure what it covers.
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Are you able to afford your Medications
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It wasn’t the cost that was a problem. I just didn’t like taking it.
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What is your access to healthcare
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I have health insurance through my job, so I can go to the doctor if I need to. It’s always a hassle though, so I try to avoid it unless I really have to like right now.
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Do you have anything that stresses you out (Clarified to Are you stressed out?.)
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Yeah, I’ve been pretty stressed lately. (Clarified to if I am stressed out.)
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What are you stressed about
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School is really busy right now, like I have a lot of projects due all around the same time. And on top of that, I’ve had to cover more at work lately, and I’m in charge of a big project at work, too.
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Sounds like you’re working really hard. I’m sorry you’re dealing with so much stress.
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Thanks for understanding.
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Tell me about your diet (Clarified to What is your diet like?.)
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It’s pretty good, I think. I’m not a huge health nut or anything. (Clarified to what my diet is like.)
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What are usually eat in a typical day
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Let’s see . . . a muffin or pumpkin bread for breakfast, a sandwich for lunch, and some kind of meat with a veggie for dinner.
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Do you have snacks
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Yeah, I usually have some snacks during the day.
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What type of snacks
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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.
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Do you exercise
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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.
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I understand being busy and having very little free time. however, exercise is healthy for you, and can even relieve stress. even small amounts of exercise, such as taking a short walk, can improve your health
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Thanks for telling me.
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Do you use any recreational drugs
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No.
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Do you use tobacco products
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No. I think it’s gross.
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Do you drink alcohol
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I do sometimes, yeah, when I go out with my friends.
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How often do you drink alcohol
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No more than once or twice a week, sometimes less.
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How much do you drink when you go out
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Just a few. I’m not a big drinker.
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How do you feel overall
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I’m feeling fine right now, but I wanted to make sure there’s nothing serious going on with my heart.
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Do you have any other symptoms
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I guess when it happens I feel a bit worried, like anxious, but that’s all.
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Do you experience any fatigue
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Yeah, most days I feel pretty exhausted by the end of the day.
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Do you have any nausea vomiting
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I haven’t had thrown up, or even had an upset stomach, in a long time.
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Have you noticed any swelling in your legs
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No, not that I have noticed.
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Do you have a family history of heart problems
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Um, none that I know of. Wait, my Poppa–that’s Mom’s dad–died of a heart attack.
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Do you have a family history of heart disease
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Um, none that I know of. Wait, my Poppa–that’s Mom’s dad–died of a heart attack.
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Any family history of high cholesterol
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Cholesterol runs high in my family. All four of my grandparents have high cholesterol, and Mom and Dad, too.
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Family history of obesity
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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.
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Family history of a stroke
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Yeah, that’s how my Nana died.
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Any family history of hypertension
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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.
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A family history of hypertension means that you may be at risk for developing it, too, and you’ve had some high blood pressure readings. keeping your blood pressure low is important to avoid health problems in the future with your health and other organs
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Alright, thanks for letting me know.
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I am going to examine you now
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Alright.
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Inspected anterior chest wall
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Inspected right side chest wall
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Inspected anterior chest wall
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Inspected left side chest wall
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Inspected anterior chest wall
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Inspected for jugular venous distention: JVP 1 cm above sternal angle
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Inspected fingernails of right hand
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Checked capillary refill in fingernails
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Checked capillary refill in fingernails
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Checked capillary refill in fingernails
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Checked capillary refill in fingernails
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Inspected fingernails of left hand
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Checked capillary refill in fingernails
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Checked capillary refill in fingernails
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Checked capillary refill in fingernails
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Checked capillary refill in fingernails
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Inspected fingernails of right hand
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Inspected legs
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Inspected right leg
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Inspected legs
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Inspected left leg
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Inspected legs
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Inspected right leg for edema: No edema
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Inspected toenails
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Checked capillary refill in toenails
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Checked capillary refill in toenails
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Checked capillary refill in toenails
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Checked capillary refill in toenails
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Checked capillary refill in toenails
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Checked capillary refill in toenails
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Checked capillary refill in toenails
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Checked capillary refill in toenails
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Checked capillary refill in toenails
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Checked capillary refill in toenails
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Inspected legs
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Inspected left leg for edema: No edema
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Palpated temporal arteries: No thrill on either side, 2+ on both sides
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Palpated temporal arteries: No thrill on either side, 2+ on both sides
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Palpated right carotid pulse: No thrill, 2+
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Palpated left carotid pulse: No thrill, 2+
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Palpated chest at PMI: Present at midclavicular line and 5th intercostal space, brisk and tapping, diameter 2 cm
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Palpated right radial pulse: No thrill, 2+
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Palpated left radial pulse: No thrill, 2+
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Palpated right brachial pulse: No thrill, 2+
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Palpated left brachial pulse: No thrill, 2+
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Palpated right femoral pulse: No thrill, 2+
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Palpated left femoral pulse: No thrill, 2+
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Palpated right popliteal pulse: No thrill, 2+
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Palpated left popliteal pulse: No thrill, 2+
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Palpated right tibial pulse: No thrill, 2+
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Palpated left tibial pulse: No thrill, 2+
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Palpated right dorsalis pedis pulse: No thrill, 2+
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Palpated left dorsalis pedis pulse: No thrill, 2+
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Auscultated right temporal pulse
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Auscultated left temporal pulse
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Auscultated right temporal pulse
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Auscultated right carotid pulse
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Auscultated left carotid pulse
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Auscultated right carotid pulse
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Auscultated breath sounds in posterior left upper lobe
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Auscultated right temporal pulse
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Auscultated breath sounds in anterior left upper lobe
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Auscultated breath sounds in anterior right upper lobe
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Auscultated breath sounds in anterior right middle lobe
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Auscultated breath sounds in anterior left mid-chest (upper lobe)
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Auscultated breath sounds in anterior right lower lobe
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Auscultated breath sounds in anterior left lower lobe
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Auscultated breath sounds in posterior left lower lobe on side
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Auscultated breath sounds in posterior left lower lobe near spine
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Auscultated breath sounds in posterior right lower lobe near spine
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Auscultated breath sounds in posterior right lower lobe on side
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Auscultated breath sounds in posterior right lower lobe
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Auscultated aortic area with the bell
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Auscultated aortic area with the diaphragm
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Auscultated pulmonic area with the diaphragm
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Auscultated Erb’s point with the diaphragm
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Auscultated tricuspid area with the diaphragm
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Auscultated mitral area with the diaphragm
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Auscultated aorta in abdomen
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Auscultated right renal pulse
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Auscultated left renal pulse
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Auscultated right iliac pulse
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Auscultated left iliac pulse
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Auscultated right femoral pulse
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Auscultated left femoral pulse
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Tested ABI: 141/145 = 0.972
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Performed EKG: Regular sinus rhythm, no ST changes
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Tested ABI: 141/145 = 0.972
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Any family history of high cholesterol
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Cholesterol runs high in my family. All four of my grandparents have high cholesterol, and Mom and Dad, too.
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A family history of hypertension means that you may be at risk for developing it, too, and you’ve had some high blood pressure readings. keeping your blood pressure low is important to avoid health problems in the future with your health and other organs
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That makes sense.
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Any family history of high cholesterol
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Cholesterol runs high in my family. All four of my grandparents have high cholesterol, and Mom and Dad, too.
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A family history of hypertension means that you may be at risk for developing it, too, and you’ve had some high blood pressure readings. keeping your blood pressure low is important to avoid health problems in the future with your health and other organs
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Empathize |
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Thanks for understanding.
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Do you know your family history of high blood pressure is a risk for heart disease
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Yeah, I know.
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A family history of hypertension means that you may be at risk for developing it, too, and you’ve had some high blood pressure readings. keeping your blood pressure low is important to avoid health problems in the future with your health and other organs
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Educate |
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Alright, thanks for letting me know.
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A family history of hypertension means that you may be at risk for developing it, too, and you’ve had some high blood pressure readings. keeping your blood pressure low is important to avoid health problems in the future with your health and other organs
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Empathize |
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Thanks for saying that.
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