Assignment: Shadow Health Cardiovascular Assessment
Assignment: Shadow Health Cardiovascular Assessment

Subjective Data Collection: 17 of 19 (89.5%)
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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
• Found:
Indicates an item that you found.
• Available:
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Category
Scored Items

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 recent episodes of palpitations
(Found)
Pro Tip: Broad questions like this one enable the patient to establish their chief complaint. Asking Tina if she’s had any problems with her heart will allow her to mention any concerns she’s recently had regarding her heart.
Example Question:
Have you ever had palpitations?
•
Finding:
Describes heart rate during episodes as feeling “faster than usual”
(Found)
Pro Tip: Broad questions like this one enable the patient to establish their chief complaint. Asking Tina if she’s had any problems with her heart will allow her to mention any concerns she’s recently had regarding her heart.
Example Question:
Have you had any problems with your heart?
History of Presenting Illness
•
Finding:
Asked about onset
•
Finding:
Reports first episode a month ago
(Found)
Pro Tip: Determining the onset of a health problem is the first step to understanding if the underlying condition is acute or chronic.
Example Question:
How long ago did you start having palpitations?
•
Finding:
Asked about frequency and duration of fast heartbeat episodes
•
Finding:
Reports episodes occur “about once a week”
(Found)
Pro Tip: Conditions, like palpitations, might change over time. Asking Tina when her palpitations began will give you a broader sense for her condition and her chief complaint.
Example Question:
When do the palpitations occur?
•
Finding:
Reports 3-4 episodes total
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina how many palpitation episodes she’s experienced in the last month specifies the way her individual symptoms manifest.
Example Question:
How many palpitation episodes have you had?
•
Finding:
Reports fast heartbeat episodes last 5-10 minutes
(Found)
Pro Tip: Conditions, like palpitations, might change over time. Asking Tina about the duration of her palpitations recently will allow you to assess the recent severity of her condition.
Example Question:
How long do your palpitations last?
•
Finding:
Asked about character of palpitations
•
Finding:
Describes palpitations as “thumping” or “pounding”
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe her palpitations specifies the way her individual symptoms manifest.
Example Question:
How does your heart feel during the palpitations?
•
Finding:
Reports episodes accompanied by mild anxiety
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina whether she is anxious during her palpitations specifies the way her individual symptoms manifest.
Example Question:
Do you feel anxious during the palpitations?
•
Finding:
Asked about aggravating factors
•
Finding:
Reports that palpitations seem to occur more often in the morning
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe when her palpitations began specifies the way her individual symptoms manifest.
Example Question:
When do you feel the palpitations?
•
Finding:
Reports episodes not exacerbated by exertion
(Available)
Pro Tip: Conditions, like palpitations, might change over time. Asking Tina if the palpitations are worse with exertion will allow you to assess the recent severity of her condition.
Example Question:
Do the palpitations get worse with exertion?
•
Finding:
Reports that episodes do not occur after eating
(Available)
Pro Tip: Some people experience palpitation after eating certain foods. Asking Tina whether she experiences palpitations after eating might indicate she is sensitive to certain foods (like foods that are spicy or contain MSG or caffeine).
Example Question:
Does food make your palpitations worse?
•
Finding:
Reports caffeine as a possible aggravating factor
(Available)
Pro Tip: Some people who drink caffeinated beverages have higher blood pressure than those who don’t drink caffeinated beverages. Asking Tina whether the caffeine is affecting her heart rate might point to the caffeine as a contributing factor to Tina’s palpitations.
Example Question:
Does the caffeine affect your heart rate?
•
Finding:
Asked about relieving factors
•
Finding:
Reports deep breathing and trying to relax
(Found)
Pro Tip: By asking Tina what relieves her palpitations you’re soliciting information about the way she treats, manages, or endures an uncomfortable symptom.
Example Question:
What relieves your palpitations?
•
Finding:
Denies medication or other treatment
(Found)
Pro Tip: Tina’s response to a question about the management of her palpitations will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.
Example Question:
What treatments have you tried for your palpitations?
Medical History
•
Finding:
Confirmed use of medications
•
Finding:
Confirms medications from previous visit
(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:
Have you started any new medications?
•
Finding:
Reports new inhaler
(Available)
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:
Do you use an inhaler?
•
Finding:
Followed up on new inhaler
•
Finding:
New inhaler is Flovent
(Available)
Pro Tip: You must find out the specific name or brand of a patient’s medication.
Example Question:
What is the name of your daily inhaler?
•
Finding:
Prescribed dose is two puffs
(Available)
Pro Tip: When you ask about the specific dosage that a patient is supposed to take, you learn more about their medication regiment, and their level of health literacy surrounding medication use.
Example Question:
How many puffs do you take of your inhaler?
•
Finding:
Inhaler is prescribed for daily use
(Available)
Pro Tip: Increased inhaler use, or using more puffs of an inhaler than prescribed, can indicate poorly managed asthma.
Example Question:
How often do you use your inhaler?
•
Finding:
Describes new inhaler regiment as effective
(Available)
Pro Tip: Finding out the patient’s perception of how effective an inhaler is gives you insight into how they feel their asthma is managed.
Example Question:
Is your inhaler working?
•
Finding:
Confirmed allergies
•
Finding:
Confirms allergies (no new allergies reported)
(Available)
Pro Tip: It’s best practice to ask a patient about her allergies each visit, even with an established patient, to uncover any new allergy triggers or symptoms.
Example Question:
Have you had any new allergies?
•
Finding:
Asked about personal history of hypertension
•
Finding:
Reports usual blood pressure “might be on the high side”
(Found)
Pro Tip: Blood pressure might change over time due to such factors as caffeine consumption, stress, diet, and exercise. Asking Tina what her usual blood pressure is will provide a baseline for comparing her last reading to her blood pressure now.
Example Question:
What is your usual blood pressure?
•
Finding:
Denies past diagnosis of hypertension
(Found)
Pro Tip: Cardiovascular disease can manifest in various conditions. Inquiring into Tina’s relevant history can reveal past diagnoses and previous conditions or concerns.
Example Question:
Have you been diagnosed with high blood pressure?
•
Finding:
Does not check BP regularly
(Found)
Pro Tip: Blood pressure might change over time due to such factors as caffeine consumption, stress, diet, and exercise. Asking Tina how frequently she checks her blood pressure will show how often she is monitoring her cardiovascular health.
Example Question:
How often do you check your blood pressure?
•
Finding:
Is aware of risk factors for hypertension
(Available)
Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking Tina if she is aware that her family history of hypertension puts her at risk for cardiovascular disease indicates Tina’s health literacy.
Example Question:
Do you know your family history of high blood pressure is a risk factor for heart disease?
•
Finding:
Asked about possible contributing factors in health history
•
Finding:
Reports no known history of heart disease
(Available)
Pro Tip: Heart disease is the umbrella term to describe many conditions that might affect your heart. Asking Tina whether she has a history of heart disease is the first question in determining her specific cardiovascular concerns.
Example Question:
Do you have any history of heart disease
•
Finding:
Reports type 2 diabetes
(Available)
Pro Tip: Adults with diabetes are between two and four times more likely to suffer from cardiovascular disease. Determining whether Tina has diabetes will indicate if she is at a higher risk for heart disease.
Example Question:
Do you have diabetes?
•
Finding:
Reports no past diagnosis of high cholesterol
(Available)
Pro Tip: High cholesterol can lead to cardiovascular disease. Asking Tina whether she’s had a history of high cholesterol reveals her recent medical history.
Example Question:
Do you have high cholesterol?
•
Finding:
Reports no history of rheumatic fever
(Available)
Pro Tip: Rheumatic fever can cause irreversible damage to the heart. Asking Tina whether she’s had rheumatic fever would point to a condition that might have affected her cardiovascular health.
Example Question:
Do you have any history of rheumatic fever?
•
Finding:
Reports no history of heart murmur
(Available)
Pro Tip: Some heart murmurs can indicate a damaged or overworked heart valve. Asking Tina whether she’s experienced a heart murmur allows you to assess whether she’s noticed a symptom that indicates a heart condition.
Example Question:
Do you have any history of heart murmur?