Started: Jun 27, 2020 | Total Time:109 min
 | Hello my name is Danielle I will be your provider today | Greet 06/27/20 3:27 PM CDT |
 | Hey. | |
| Can you verify your name | Question 06/27/20 3:27 PM CDT |
| Tina Jones. | |
| Your date of birth | Question 06/27/20 3:27 PM CDT |
| February 17th. | |
| Thank you | Question 06/27/20 3:27 PM CDT |
| You’re welcome. | |
| What brings you in today | Question 06/27/20 3:27 PM CDT |
| I’ve been noticing my heart seems to be beating too fast every once in a while lately, and it started to worry me. My mom said I should make an appointment. You don’t want to ignore heart stuff, I guess. | |
| I’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 | Empathize 06/27/20 3:29 PM CDT |
| Thanks for saying that. | |
| When did you first notice these symptoms | Question 06/27/20 3:30 PM CDT |
| I think the first time was about a month ago. | |
| What were you doing when you noticed these symptoms (Clarified to What were you doing when you got the palpitations?.) | Question 06/27/20 3:30 PM CDT |
| I usually notice them on my way to class in the mornings. My schoolwork has really been picking up and I’ve been drinking energy drinks to help keep me focused during the day, so maybe the caffeine or whatever else is in those things has something to do with it. (Clarified to what I was doing when the palpitations occured.) | |
| How many energy drinks do you drink per day | Question 06/27/20 3:31 PM CDT |
| Usually just one in the morning, kind of like some people have a cup of coffee. Some mornings lately I’ve had two, though. | |
| 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 | Educate 06/27/20 3:33 PM CDT |
| Sure, I think I understand what you mean. | |
| How often were you experiencing these symptoms | Question 06/27/20 3:33 PM CDT |
| No. | |
| How often do you notice your heart racing fast (Clarified to How often does your heart beat fast?.) | Question 06/27/20 3:33 PM CDT |
| It’s been about once a week for the past month. (Clarified to how often my heart beats fast.) | |
| Can you describe it for me (Clarified to What is your heartbeat like?.) | Question 06/27/20 3:34 PM CDT |
| It’s usually normal, but it’s way faster during these episodes I’ve been having. (Clarified to what my heartbeat is like.) | |
| How do you feel when your heart is racing fast | Question 06/27/20 3:34 PM CDT |
| Well, when my heart starts beating really fast, it just feels like a thumping in my chest. It makes me anxious and uncomfortable. | |
| Is there anything that relieves the fast heartbeat (Clarified to Does anything relieve your symptoms?.) | Question 06/27/20 3:35 PM CDT |
| I haven’t tried anything specific, other than just trying to relax and breathe deep. (Clarified to if anything relieves my symptoms.) | |
| Do you take any medications to help you with your symptoms | Question 06/27/20 3:35 PM CDT |
| Nope. | |
| What medications are you taking | Question 06/27/20 3:35 PM CDT |
| I have a daily inhaler and a rescue inhaler for my asthma. | |
| Are you taking any new medications | Question 06/27/20 3:36 PM CDT |
| Yeah, I have a daily inhaler now that I’ve been using. | |
| What’s the name of the medication | Question 06/27/20 3:36 PM CDT |
| The daily inhaler is Flovent, and the rescue inhaler is Proventil. | |
| Do you have any new allergies | Question 06/27/20 3:36 PM CDT |
| No, not that I know of. | |
| Do you have a history of hypertension | Question 06/27/20 3:37 PM CDT |
| …I’ve never been diagnosed with blood pressure problems. But I think it can be on the high side sometimes. | |
| Do you check your blood pressure | Question 06/27/20 3:37 PM CDT |
| Only when I’m here at the clinic. | |
| Do you have any health history that would contribute to hypertension (No matching questions found.) | Question 06/27/20 3:38 PM CDT |
| Do you have diabetes | Question 06/27/20 3:38 PM CDT |
| Yeah, I was diagnosed a few years ago. | |
| Do you have high cholesterol | Question 06/27/20 3:38 PM CDT |
| I’ve never had it tested. My family has problems with high cholesterol, but I don’t think I do. | |
| Any history of a heart murmur | Question 06/27/20 3:38 PM CDT |
| No. | |
| Do you have health insurance | Question 06/27/20 3:39 PM CDT |
| I have health insurance through work. To be honest, though, I’m not exactly sure what it covers. | |
| Are you able to afford your Medications | Question 06/27/20 3:41 PM CDT |
| It wasn’t the cost that was a problem. I just didn’t like taking it. | |
| What is your access to healthcare | Question 06/27/20 3:42 PM CDT |
| 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. | |
| Do you have anything that stresses you out (Clarified to Are you stressed out?.) | Question 06/27/20 3:44 PM CDT |
| Yeah, I’ve been pretty stressed lately. (Clarified to if I am stressed out.) | |
| What are you stressed about | Question 06/27/20 3:44 PM CDT |
| 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. | |
| Sounds like you’re working really hard. I’m sorry you’re dealing with so much stress. | Empathize 06/27/20 3:45 PM CDT |
| Thanks for understanding. | |
| Tell me about your diet (Clarified to What is your diet like?.) | Question 06/27/20 3:46 PM CDT |
| It’s pretty good, I think. I’m not a huge health nut or anything. (Clarified to what my diet is like.) | |
| What are usually eat in a typical day | Question 06/27/20 3:46 PM CDT |
| Let’s see . . . a muffin or pumpkin bread for breakfast, a sandwich for lunch, and some kind of meat with a veggie for dinner. | |
| Do you have snacks | Question 06/27/20 3:46 PM CDT |
| Yeah, I usually have some snacks during the day. | |
| What type of snacks | Question 06/27/20 3:46 PM CDT |
| I try to eat snacks that are kind of healthy like pretzels–sometimes if I’ll treat myself and get french fries, but I try not to do that too often. | |
| Do you exercise | Question 06/27/20 3:47 PM CDT |
| I’m pretty exhausted by the end of the day, so I don’t have the energy to do any extra exercise. But I’m on my feet all the time at work so I feel like that’s a little bit of exercise most days at least. | |
| I understand 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 | Educate 06/27/20 3:49 PM CDT |
| Thanks for telling me. | |
| Do you use any recreational drugs | Question 06/27/20 3:49 PM CDT |
| No. | |
| Do you use tobacco products | Question 06/27/20 3:49 PM CDT |
| No. I think it’s gross. | |
| Do you drink alcohol | Question 06/27/20 3:50 PM CDT |
| I do sometimes, yeah, when I go out with my friends. | |
| How often do you drink alcohol | Question 06/27/20 3:50 PM CDT |
| No more than once or twice a week, sometimes less. | |
| How much do you drink when you go out | Question 06/27/20 3:50 PM CDT |
| Just a few. I’m not a big drinker. | |
| How do you feel overall | Question 06/27/20 3:51 PM CDT |
| I’m feeling fine right now, but I wanted to make sure there’s nothing serious going on with my heart. | |
| Do you have any other symptoms | Question 06/27/20 3:51 PM CDT |
| I guess when it happens I feel a bit worried, like anxious, but that’s all. | |
| Do you experience any fatigue | Question 06/27/20 3:51 PM CDT |
| Yeah, most days I feel pretty exhausted by the end of the day. | |
| Do you have any nausea vomiting | Question 06/27/20 3:51 PM CDT |
| I haven’t had thrown up, or even had an upset stomach, in a long time. | |
| Have you noticed any swelling in your legs | Question 06/27/20 3:52 PM CDT |
| No, not that I have noticed. | |
| Do you have a family history of heart problems | Question 06/27/20 3:52 PM CDT |
| Um, none that I know of. Wait, my Poppa–that’s Mom’s dad–died of a heart attack. | |
| Do you have a family history of heart disease | Question 06/27/20 3:52 PM CDT |
| Um, none that I know of. Wait, my Poppa–that’s Mom’s dad–died of a heart attack. | |
| Any family history of high cholesterol | Question 06/27/20 3:53 PM CDT |
| Cholesterol runs high in my family. All four of my grandparents have high cholesterol, and Mom and Dad, too. | |
| Family history of obesity | Question 06/27/20 3:53 PM CDT |
| No, I don’t think so. My brother and my dad are kind of big, but I wouldn’t say they were obese or anything. | |
| Family history of a stroke | Question 06/27/20 3:53 PM CDT |
| Yeah, that’s how my Nana died. | |
| Any family history of hypertension | Question 06/27/20 3:53 PM CDT |
| We’ve got high blood pressure in our family for sure. Granny, Mom, and Dad had it…and honestly I think my other three grandparents might’ve had issues with that, too. | |
| 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 | Educate 06/27/20 3:55 PM CDT |
| Alright, thanks for letting me know. | |
| I am going to examine you now | Question 06/27/20 3:56 PM CDT |
| Alright. | |
| Inspected anterior chest wall | Exam Action 06/27/20 3:56 PM CDT |
| Inspected right side chest wall | Exam Action 06/27/20 3:56 PM CDT |
| Inspected anterior chest wall | Exam Action 06/27/20 3:56 PM CDT |
| Inspected left side chest wall | Exam Action 06/27/20 3:56 PM CDT |
| Inspected anterior chest wall | Exam Action 06/27/20 3:56 PM CDT |
| Inspected for jugular venous distention: JVP 1 cm above sternal angle | Exam Action 06/27/20 3:56 PM CDT |
| Inspected fingernails of right hand | Exam Action 06/27/20 3:57 PM CDT |
| Checked capillary refill in fingernails | Exam Action 06/27/20 3:57 PM CDT |
| Checked capillary refill in fingernails | Exam Action 06/27/20 3:57 PM CDT |
| Checked capillary refill in fingernails | Exam Action 06/27/20 3:57 PM CDT |
| Checked capillary refill in fingernails | Exam Action 06/27/20 3:57 PM CDT |
| Inspected fingernails of left hand | Exam Action 06/27/20 3:57 PM CDT |
| Checked capillary refill in fingernails | Exam Action 06/27/20 3:58 PM CDT |
| Checked capillary refill in fingernails | Exam Action 06/27/20 3:58 PM CDT |
| Checked capillary refill in fingernails | Exam Action 06/27/20 3:58 PM CDT |
| Checked capillary refill in fingernails | Exam Action 06/27/20 3:58 PM CDT |
| Inspected fingernails of right hand | Exam Action 06/27/20 3:58 PM CDT |
| Inspected legs | Exam Action 06/27/20 3:59 PM CDT |
| Inspected right leg | Exam Action 06/27/20 3:59 PM CDT |
| Inspected legs | Exam Action 06/27/20 3:59 PM CDT |
| Inspected left leg | Exam Action 06/27/20 3:59 PM CDT |
| Inspected legs | Exam Action 06/27/20 3:59 PM CDT |
| Inspected right leg for edema: No edema | Exam Action 06/27/20 3:59 PM CDT |
| Inspected toenails | Exam Action 06/27/20 3:59 PM CDT |
| Checked capillary refill in toenails | Exam Action 06/27/20 3:59 PM CDT |
| Checked capillary refill in toenails | Exam Action 06/27/20 3:59 PM CDT |
| Checked capillary refill in toenails | Exam Action 06/27/20 4:00 PM CDT |
| Checked capillary refill in toenails | Exam Action 06/27/20 4:00 PM CDT |
| Checked capillary refill in toenails | Exam Action 06/27/20 4:00 PM CDT |
| Checked capillary refill in toenails | Exam Action 06/27/20 4:00 PM CDT |
| Checked capillary refill in toenails | Exam Action 06/27/20 4:00 PM CDT |
| Checked capillary refill in toenails | Exam Action 06/27/20 4:00 PM CDT |
| Checked capillary refill in toenails | Exam Action 06/27/20 4:00 PM CDT |
| Checked capillary refill in toenails | Exam Action 06/27/20 4:00 PM CDT |
| Inspected legs | Exam Action 06/27/20 4:00 PM CDT |
| Inspected left leg for edema: No edema | Exam Action 06/27/20 4:00 PM CDT |
| Palpated temporal arteries: No thrill on either side, 2+ on both sides | Exam Action 06/27/20 4:02 PM CDT |
| Palpated temporal arteries: No thrill on either side, 2+ on both sides | Exam Action 06/27/20 4:03 PM CDT |
| Palpated right carotid pulse: No thrill, 2+ | Exam Action 06/27/20 4:03 PM CDT |
| Palpated left carotid pulse: No thrill, 2+ | Exam Action 06/27/20 4:03 PM CDT |
| Palpated chest at PMI: Present at midclavicular line and 5th intercostal space, brisk and tapping, diameter 2 cm | Exam Action 06/27/20 4:04 PM CDT |
| Palpated right radial pulse: No thrill, 2+ | Exam Action 06/27/20 4:05 PM CDT |
| Palpated left radial pulse: No thrill, 2+ | Exam Action 06/27/20 4:05 PM CDT |
| Palpated right brachial pulse: No thrill, 2+ | Exam Action 06/27/20 4:05 PM CDT |
| Palpated left brachial pulse: No thrill, 2+ | Exam Action 06/27/20 4:05 PM CDT |
| Palpated right femoral pulse: No thrill, 2+ | Exam Action 06/27/20 4:06 PM CDT |
| Palpated left femoral pulse: No thrill, 2+ | Exam Action 06/27/20 4:06 PM CDT |
| Palpated right popliteal pulse: No thrill, 2+ | Exam Action 06/27/20 4:06 PM CDT |
| Palpated left popliteal pulse: No thrill, 2+ | Exam Action 06/27/20 4:06 PM CDT |
| Palpated right tibial pulse: No thrill, 2+ | Exam Action 06/27/20 4:07 PM CDT |
| Palpated left tibial pulse: No thrill, 2+ | Exam Action 06/27/20 4:07 PM CDT |
| Palpated right dorsalis pedis pulse: No thrill, 2+ | Exam Action 06/27/20 4:07 PM CDT |
| Palpated left dorsalis pedis pulse: No thrill, 2+ | Exam Action 06/27/20 4:07 PM CDT |
| Auscultated right temporal pulse | Exam Action 06/27/20 4:08 PM CDT |
| Auscultated left temporal pulse | Exam Action 06/27/20 4:08 PM CDT |
| Auscultated right temporal pulse | Exam Action 06/27/20 4:08 PM CDT |
| Auscultated right carotid pulse | Exam Action 06/27/20 4:12 PM CDT |
| Auscultated left carotid pulse | Exam Action 06/27/20 4:12 PM CDT |
| Auscultated right carotid pulse | Exam Action 06/27/20 4:12 PM CDT |
| Auscultated breath sounds in posterior left upper lobe | Exam Action 06/27/20 4:13 PM CDT |
| Auscultated right temporal pulse | Exam Action 06/27/20 4:13 PM CDT |
| Auscultated breath sounds in anterior left upper lobe | Exam Action 06/27/20 4:13 PM CDT |
| Auscultated breath sounds in anterior right upper lobe | Exam Action 06/27/20 4:13 PM CDT |
| Auscultated breath sounds in anterior right middle lobe | Exam Action 06/27/20 4:13 PM CDT |
| Auscultated breath sounds in anterior left mid-chest (upper lobe) | Exam Action 06/27/20 4:13 PM CDT |
| Auscultated breath sounds in anterior right lower lobe | Exam Action 06/27/20 4:13 PM CDT |
| Auscultated breath sounds in anterior left lower lobe | Exam Action 06/27/20 4:14 PM CDT |
| Auscultated breath sounds in posterior left lower lobe on side | Exam Action 06/27/20 4:14 PM CDT |
| Auscultated breath sounds in posterior left lower lobe near spine | Exam Action 06/27/20 4:14 PM CDT |
| Auscultated breath sounds in posterior right lower lobe near spine | Exam Action 06/27/20 4:14 PM CDT |
| Auscultated breath sounds in posterior right lower lobe on side | Exam Action 06/27/20 4:14 PM CDT |
| Auscultated breath sounds in posterior right lower lobe | Exam Action 06/27/20 4:14 PM CDT |
| Auscultated aortic area with the bell | Exam Action 06/27/20 4:14 PM CDT |
| Auscultated aortic area with the diaphragm | Exam Action 06/27/20 4:14 PM CDT |
| Auscultated pulmonic area with the diaphragm | Exam Action 06/27/20 4:15 PM CDT |
| Auscultated Erb’s point with the diaphragm | Exam Action 06/27/20 4:15 PM CDT |
| Auscultated tricuspid area with the diaphragm | Exam Action 06/27/20 4:15 PM CDT |
| Auscultated mitral area with the diaphragm | Exam Action 06/27/20 4:15 PM CDT |
| Auscultated aorta in abdomen | Exam Action 06/27/20 4:15 PM CDT |
| Auscultated right renal pulse | Exam Action 06/27/20 4:15 PM CDT |
| Auscultated left renal pulse | Exam Action 06/27/20 4:15 PM CDT |
| Auscultated right iliac pulse | Exam Action 06/27/20 4:16 PM CDT |
| Auscultated left iliac pulse | Exam Action 06/27/20 4:16 PM CDT |
| Auscultated right femoral pulse | Exam Action 06/27/20 4:16 PM CDT |
| Auscultated left femoral pulse | Exam Action 06/27/20 4:16 PM CDT |
| Tested ABI: 141/145 = 0.972 | Exam Action 06/27/20 4:16 PM CDT |
| Performed EKG: Regular sinus rhythm, no ST changes | Exam Action 06/27/20 4:17 PM CDT |
| Tested ABI: 141/145 = 0.972 | Exam Action 06/27/20 4:17 PM CDT |
| Any family history of high cholesterol | Question 06/27/20 5:40 PM CDT |
| Cholesterol runs high in my family. All four of my grandparents have high cholesterol, and Mom and Dad, too. | |
| 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 | Educate 06/27/20 5:40 PM CDT |
| That makes sense. | |
| Any family history of high cholesterol | Question 06/27/20 5:41 PM CDT |
| Cholesterol runs high in my family. All four of my grandparents have high cholesterol, and Mom and Dad, too. | |
| 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 | Empathize 06/27/20 5:42 PM CDT |
| Thanks for understanding. | |
| Do you know your family history of high blood pressure is a risk for heart disease | Question 06/27/20 5:45 PM CDT |
| Yeah, I know. | |
| 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 | Educate 06/27/20 5:45 PM CDT |
| Alright, thanks for letting me know. | |
| 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 | Empathize 06/27/20 5:45 PM CDT |
| Thanks for saying that. |
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