Cardiac Complaint Assessment: Patient Interview and Medical History, Exams of Nursing

Download Cardiac Complaint Assessment: Patient Interview and Medical History and more Exams Nursing in PDF only on Docsity! New NURSING 500 Brian Foster Chest Pain Subjective data collection 2022/23///// Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Chief Complaint • Finding: Established chief complaint • Finding: Reports sporadic chest pain (Found) Pro Tip: Chest pain can be a sign of many health problems, some serious and some less serious. It is important to follow up with discovery of chest pain by asking about its characteristics and severity. Example Question: Do you have chest pain? History of Present Illness • Finding: Asked about onset of pain • Finding: Reports chest pain started appearing in the past month (Available) Pro Tip: Establishing the onset of a patient's pain is essential in diagnosing its severity as well as the comfort of the patient. 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: Identifying the location of a patient's pain is essential in determining which body systems are affected, the underlying cause of the pain, and how best to treat it. Example Question: Where is the pain? • Finding: Reports pain does not radiate (Found) Pro Tip: Pain radiation is an important symptom that can be helpful in understanding the cause of pain and narrowing the diagnosis. Example Question: Does the pain radiate? • Finding: Are you experiencing neck pain? • Finding: Asked about duration of pain episodes • Finding: Reports each episode lasted "several" minutes (Found) Pro Tip: Knowing the duration of a patient's pain gives you a more complete picture of its severity and potential impact on the patient's health. Example Question: How long does your chest pain last? • Finding: Asked about frequency of pain • Finding: Reports 3 episodes in past month (Found) Pro Tip: Establishing a timeline for a patient's symptoms can help you to better diagnose his condition and most effectively treat him. Example Question: How many times in the last month have you had chest pain? • Finding: Reports that episodes did not seem related (Available) Pro Tip: Asking your patient if the episodes seem associated can point to possible factors that aggravate the episodes or trigger symptoms, and can help narrow your diagnosis. Example Question: Did the episodes seem associated? Can you describe your pain? • Finding: Denies crushing pain (Available) Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning. Example Question: Is the pain crushing? • Finding: Denies gnawing pain (Available) Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning. Example Question: Is the pain gnawing? • Finding: Denies burning pain (Available) Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning. Example Question: Is the pain burning? • Finding: Asked about aggravating factors • Finding: Reports pain is aggravated by activity (Found) Pro Tip: Aggravating factors reveal further information about the nature of the pain and the body systems affected. Example Question: What makes the pain worse? • Finding: Pain occurred with yard work and taking stairs (Found) Pro Tip: Determining the activity that may have caused the patient's complaint is crucial because it may reveal the root cause of the complaint. Example Question: What activity triggered the pain? • Finding: Pain does not worsen with eating (Available) Pro Tip: It is important to ask about the patient's diet and its impact on his complaint because cardiac complaints and gastrointestinal pain can be very similar and are frequently conflated. Ruling out one or the other can assist your diagnosis. Example Question: Is the pain worse when you eat? • Finding: Reports no medication to treat chest pain (Found) Pro Tip: It's important to assess the nature of pain by asking about relief. Discovering any pain medication Brian takes can help you assess the nature and severity of his pain and avoid any unwanted medication interactions. Example Question: Did you take anything for the chest pain? Medical History • Finding: Confirmed use of medications • Finding: Confirms medications (Found) Pro Tip: Determining what, if any, medications a patient is taking is a crucial element of a thorough health history and will help you avoid unwanted drug interactions. Example Question: What medications do you take? • Finding: Reports taking hypertension medication (Found) Pro Tip: The medication that a patient takes will indicate any relevant health conditions, their treatment plan, and how well they comply with it. Asking about relevant medication will help you to treat your patient. Example Question: Do you take medication for hypertension? • Finding: Reports taking hyperlipidemia medication (Found) Example Question: Do you take aspirin? • Finding: Followed up on hypertension treatment • Finding: Medication is Lopressor (Found) Pro Tip: Discovering which specific medications a patient takes helps you assess his health conditions, effectiveness of treatment, and guards against unwanted medication interactions. Example Question: What medication do you take for hypertension? • Finding: Lopressor dose is 100mg (Available) Pro Tip: The current dose of any patient's prescription medications is important to learn about because it provides useful information about the patient's treatment plan as well as potential medication interactions. Example Question: What dose of medication do you take for hypertension? • Finding: Takes Lopressor once daily (Available) Pro Tip: The frequency with which a patient takes his medications is an essential element of the complete picture of his medication treatment plan. Example Question: How frequently do you take medication for hypertension? • Finding: Followed up on hyperlipidemia treatment • Finding: Medication is Lipitor (Found) Pro Tip: Discovering which specific medications a patient takes helps you assess his health conditions, effectiveness of treatment, and guards against unwanted medication interactions. Example Question: What medication do you take for hyperlipidemia? • Finding: Lipitor dose is 20mg (Available) Pro Tip: The current dose of any patient's prescription medications is important to learn about because it provides useful information about the patient's treatment plan as well as potential medication interactions. Example Question: What dose of medication do you take for hyperlipidemia? • Finding: Takes Lipitor once daily (Available) Pro Tip: The frequency with which a patient takes his medications is an essential element of the complete picture of his medication treatment plan. Do you have new allergies? • Finding: Asked about possible contributing factors in health history • Finding: Reports no known diagnosis of angina (Available) Pro Tip: A history of angina can weaken the heart and lead to further cardiovascular complications. Asking Brian about angina helps you understand his overall cardiovascular health. Example Question: Do you have a history of angina? • Finding: Reports hypertension (Found) Pro Tip: Hypertension is the most important risk factor for stroke. Soliciting a health history from Brian will allow you to assess his risk of cardiovascular disease. Example Question: Do you have hypertension? • Finding: Reports high cholesterol (Found) Pro Tip: High cholesterol can lead to cardiovascular disease. Asking Brian whether he's had a history of high cholesterol reveals important details about his cardiovascular health. Example Question: Do you have high cholesterol? • Finding: (Available) Pro Tip: Monitoring blood pressure helps to keep track of a patient's cardiovascular health. Asking Brian how often he measures his blood pressure will indicate his health literacy and a current treatment plan. Example Question: How often do you measure your blood pressure? • Finding: Reports infrequent BP checks at the doctor or drugstore (Available) Pro Tip: Monitoring blood pressure helps to keep track of a patient's cardiovascular health. Asking Brian when he measures his blood pressure will indicate his health literacy and a current treatment plan. Example Question: When do you measure your blood pressure? • Finding: Reports not remembering typical BP reading (Available) Pro Tip: Monitoring blood pressure helps to keep track of a patient's cardiovascular health. Asking Brian what his typical blood pressure reading is will indicate his health literacy and a current treatment plan. Example Question: What is your typical blood pressure reading? • Finding: Asked about past cardiac tests • Finding: Reports recent EKG test (Available) Pro Tip: An EKG test checks for electrical problems with the heart. Asking Brian whether he's had an EKG will reveal his recent medical history, cardiac health, and medical literacy. Example Question: Have you recently had an EKG? • Finding: Reports annual stress test (Available) Pro Tip: A stress test can illustrate the amount of stress a patient's heart can handle before developing irregular rhythm. Asking Brian if he's recently had a stress test will indicate a treatment plan, cardiac health, and health literacy. Example Question: Have you recently had a stress test? • Finding: Followed up on results of cardiac tests • Finding: Reports belief that EKG was normal (Available) Pro Tip: An EKG test checks for electrical problems with the heart. Asking Brian whether he's had an EKG will reveal his recent medical history, cardiac health, and medical literacy. Example Question: What were the results of your last EKG? • Finding: Usually sees doctor every 6 months (Available) Pro Tip: Asking how frequently Brian sees a healthcare provider is important in determining his current health care access, health status, and treatment plans. Example Question: How often do you see a healthcare provider? Social History • Finding: Asked about stress • Finding: Reports generally low stress lifestyle (Available) Pro Tip: Stress can have a profound effect on the patient's health and wellness. Asking about stress is an important part of any health assessment. Example Question: What is your stress level? • Finding: Asked about exercise • Finding: Denies regular exercise routine (Found) Pro Tip: Activity levels have an important impact on cardiovascular health. Asking Brian about his exercise patterns can help you understand how his lifestyle might affect his health. Example Question: What kind of exercise do you get? • Finding: Typical dinner is grilled meat and vegetables (Found) Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Brian about his typical dinner will allow you to assess whether his eating habits put him at risk of cardiovascular disease or other health complications. Example Question: What is a typical dinner for you? • Finding: Denies moderation of salt intake (Available) Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Salt intake in particular can have a detrimental effect on blood pressure, which is why it is important to ask a patient like Brian, who suffers from hypertension, about his salt consumption. Example Question: Do you moderate your salt intake? • Finding: Asked about liquid intake • Finding: Reports regular water intake (Available) Pro Tip: Insufficient water intake can lead to dehydration and fatigue. Asking Brian how much water he drinks every day will indicate whether he is drinking sufficient fluids. Example Question: Do you drink water every day? • Finding: Drinks a liter of water a day (Available) Pro Tip: Insufficient water intake can lead to dehydration and fatigue. Asking Brian how much water he drinks every day will indicate whether he is drinking sufficient fluids. Example Question: How much water do you drink per day? • Finding: Drinks 2 cups of coffee daily (Available) Pro Tip: Coffee is a diuretic and thus causes the patient to lose fluids. Asking Brian how much coffee he drinks per day will help you to assess the level of his fluid intake. Example Question: How much coffee do you drink per day? • Finding: Denies soda drinking (Available) Pro Tip: Soda is high in sugar and Insufficient water intake can lead to dehydration and fatigue. Asking Brian how much soda he drinks every day will indicate whether his fluid intake is primarily water or soda. Example Question: How much soda do you drink per day? • Finding: Asked about substance use • Finding: (Found) Pro Tip: Consumption of alcohol can impact a patient's health and is considered a risk factor for many medical conditions. Asking Brian about his drinking habits will help you determine his risk for disease linked to alcohol consumption. Example Question: Do you drink alcohol? • Finding: Reports 2-3 drinks in one sitting / night (Available) Pro Tip: Asking the patient to quantify his drinking is helpful because it elicits objective data on a subject that patients may otherwise downplay. Example Question: How many alcoholic drinks do you have in one sitting? • Finding: Reports drinking only on weekends (Found) Pro Tip: Asking the patient to describe his drinking habits can identify indicators of alcoholism. It may also be helpful to ask about the context and reasons for the patient's alcohol intake. Heavy drinkers will often underestimate their drinking habits. Example Question: When do you drink alcohol? Review of Systems • Finding: Asked about general symptoms • Finding: Denies fever (Found) • Finding: Denies weight loss (Found) Pro Tip: Unintentional weight loss can be a distressing symptom for many body systems. It is important to ask about weight loss to rule out conditions that may be associated with it. Example Question: Have you experienced recent weight loss? • Finding: Denies dizziness or lightheadedness (Available) Pro Tip: Patients exhibiting dizziness may be at risk for several conditions as well as a fall risk. It is important to ask about dizziness to keep your patient safe. Example Question: Do you have dizziness? • Finding: Denies palpitations (Found) Pro Tip: Discovering palpitations can be an important clue into the patient's cardiovascular history and current condition. Example Question: Do you have palpitations? • Finding: Asked review of systems for cardiovascular • Finding: Denies history of angina (Available) Pro Tip: A history of angina can weaken the heart and lead to further cardiovascular complications. Asking Brian about angina helps you understand his overall cardiovascular health. Example Question: Do you have a history of angina? • Finding: Denies edema (Found) Pro Tip: Swelling can be a major indicator of cardiovascular and peripheral vascular health. Asking the patient about swelling is an important part of a thorough cardio exam. Example Question: Do you have any swelling? • Finding: Denies circulation problems (Available) Pro Tip: Circulation is an important indicator of peripheral vascular and cardiovascular health. Asking Brian about his circulation can help diagnose vascular conditions. Example Question: Do you have any problems with circulation? • Finding: Have you noticed any unusual bleeding? • Finding: Denies easy bruising (Available) Pro Tip: Ease of bruising can be a sign of serious cardiovascular or related illnesses. Asking Brian about bruising can provide valuable information about the state of his cardiovascular health. Example Question: Have you noticed any unusual bruising? • Finding: Denies cyanosis (Found) Pro Tip: Cyanosis can be a symptom of troubling cardiovascular illness, though patients may not be aware of the connection to cardiovascular health. Asking Brian if he has noticed any cyanosis is important in ruling out certain cardiac risk factors. Example Question: Has your facial skin ever turned blue? • Finding: Asked about review of systems for respiratory • Finding: Denies cough (Found) Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the respiratory system. A cough in a patient complaining of chest pain is a symptom worth investigating. Example Question: Do you have a cough? • Finding: Denies sore throat (Available) Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the respiratory system. A sore throat in a patient complaining of chest pain is a symptom worth investigating. Example Question: Do you have a sore throat? • Finding: Denies dysphagia (Available) Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the respiratory system. Painful or difficult swallowing in a patient complaining of chest pain is a symptom worth investigating. Example Question: Do you have dysphagia? • Finding: Asked about review of systems for gastrointestinal • Finding: Denies nausea (Found) Pro Tip: Nausea can be an urgent symptom and sign of distress in more than one body symptom. Assessing and treating a patient's nausea is important in a cardiovascular exam. Example Question: Do you have nausea? • Finding: Denies vomiting (Found) Pro Tip: Vomiting can be a major indicator of multiple health problems. Asking the patient about vomiting is an important part of a thorough cardio exam. Example Question: Have you vomited recently? • Finding: Denies diarrhea (Available) Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the gastrointestinal system. Diarrhea in a patient complaining of chest pain is a symptom worth investigating. Example Question: Do you have diarrhea? • Finding: Denies constipation (Available) Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the gastrointestinal system. Constipation in a patient complaining of chest pain is a symptom worth investigating. Example Question: Do you have constipation? • Finding: GERD are of particular importance to ask about, since their symptoms closely follow the symptoms of cardiac pain. Example Question: Do you have heartburn or GERD? Family History • Finding: Asked about relevant family history • Finding: Reports family history of heart attack (Found) Pro Tip: Family health history is an important genetic indicator of a patient's predisposition to certain medical conditions. Asking Brian if anyone in his family has suffered a heart attack helps you develop a more complete picture of his cardiovascular health. Example Question: Has anyone in your family had a heart attack? • Finding: Denies family history of stroke (Available) Pro Tip: Family health history is an important genetic indicator of a patient's predisposition to certain medical conditions. Asking Brian if anyone in his family has suffered a stroke helps you develop a more complete picture of his cardiovascular health. Example Question: Do you have a family history of stroke? • Finding: Denies family history of pulmonary embolism