Liam Fitzgerald Telehealth Follow Up Sick Visit: Management of Cardiovascular Conditions Patient Objective Data Collection: 2 of 2 (100%)
Checked Ankles
1 of 1 point
Right Ankle (1/2 point)
No unusual findings visible
Swelling
Visible lump
Irregular alignment
Change in color
Joint deformity
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Left Ankle (1/2 point)
No unusual findings visible
Swelling
Visible lump
Irregular alignment
Change in color
Joint deformity
Touched Ankles
0.75 of 1 point
Left Ankle Touch (1/4 point)
No abnormalities found
Soreness
Warmth
Redness
Swelling
Right Ankle Touch (1/4 point)
Brian Foster Conditions of the Cardiovascular System Test Selection
No abnormalities found
Soreness
Warmth
Redness
Swelling
Ankle Pitting Test – Left (1/4 point)
No pitting
1+ Slight pitting
2+ Deeper pit, disappears in 10-15 seconds
3+ Noticeably deep pit that lasts for more than a minute
4+ Very deep pit that lasts 2 to 5 minutes
Ankle Pitting Test – Right (1/4 point)
No pitting
1+ Slight pitting
2+ Deeper pit, disappears in 10-15 seconds
3+ Noticeably deep pit that lasts for more than a minute
4+ Very deep pit that lasts 2 to 5 minutes
Education & Empathy
Throughout the patient interview, there are numerous opportunities for patient education and empathy. The following are key moments identified by healthcare experts for this patient. A sample statement is provided as an example of an appropriate response to each opportunity.
– Opportunities marked as “Not Encountered” were not brought up during the interview.
– Opportunities marked as “Not Followed Up” were present but not addressed in the conversation.
– Opportunities marked as “Followed Up” were acknowledged and discussed during the conversation.
1. Swelling and Weight Gain
– Followed Up
– Description: Mr. Fitzgerald is experiencing swelling and rapid weight gain.
This is your virtual self.
Any issues with weight? (Clarified to: Have you lost weight?)
Question
06:14 PM EDT
Liam Fitzgerald
No, I’ve actually gained some. (Clarified to: if I have lost weight)
This is your virtual self.
Gaining weight will only worsen your heart problems
Educate
06:15 PM EDT
Liam Fitzgerald
Understood. Thank you.
Model Statement: “You should be aware of what signs and symptoms may indicate worsening heart failure so that you can react appropriately if they arise. For example, the rapid weight gain you experienced over the last 24 hours or the swelling in your lower extremities indicates a fluid volume overload in your body and that your congestive heart failure is worsening. Paying attention to these signs and symptoms can help you determine if you need to take your diuretic. However, if you continue to swell and gain weight, you should contact your healthcare provider and seek emergency medical care, as these are signs of a congestive heart failure exacerbation.”
2. Taking Diuretics
– Not Encountered
– Description: Mr. Fitzgerald has experienced signs and symptoms that indicate he should use his as-needed medications, furosemide and potassium chloride.
Model Statement: “You should take your furosemide 20 mg and potassium chloride tablet 10 mEq as needed when you exhibit abnormal signs and symptoms, like swelling and weight gain. Even though the swelling you are experiencing in your lower extremities is minor, it can still have a great effect on your cardiovascular functioning. Taking the furosemide and potassium chloride tablets upon the onset of swelling will help control this symptom and maintain your cardiovascular health. However, if your symptoms worsen or do not resolve, you should contact your healthcare provider and seek emergency medical care.”
3. Diet Adherence
– Not Encountered
– Description: Mr. Fitzgerald recently consumed a meal of high-sodium foods at his grandson’s party.
Model Statement: “It can be challenging to adhere to your low-sodium diet all the time, especially in social situations. However, not following your usual low-sodium diet can negatively impact your cardiovascular health and exacerbate your congestive heart failure. The large quantity of high-sodium foods you ate at the recent party led to a fluid volume overload and resulted in your rapid weight gain and the swelling in your extremities. Adhering to your diet will help prevent fluctuations in your cardiovascular health and reduce the risk of exacerbating your congestive heart failure.”
4. Waking Up at Night
– Not Followed Up
– Description: Mr. Fitzgerald has been experiencing nocturia four to five nights a week.
This is your virtual self.
Any issues with urination?
Question
06:26 PM EDT
Liam Fitzgerald
No issues with urination, but I do wake up needing to urinate at night.
This is your virtual self.
Any weakness?
Question
06:26 PM EDT
Liam Fitzgerald
I’m no superhero, but I can still open pickle jars when needed.
This is your virtual self.
Any breathing problems?
Question
06:26 PM EDT
Liam Fitzgerald
I haven’t had any issues with my breathing.
Model Statement: “I’m sorry to hear your sleep has been disrupted by having to wake up frequently to use the bathroom. Having a restful, uninterrupted sleep is important for your physical and emotional health, and disruptions to this can be very irritating. If you need to take your diuretic, do so in the morning if appropriate to avoid triggering nocturia. If your nocturia worsens, follow-up with your healthcare provider as it may be an indication of an underlying or worsening condition.”
Liam Fitzgerald Telehealth Follow Up Sick Visit: Management of Cardiovascular Conditions Patient Objective Data Collection
Objective Data Collection: 2 of 2 (100%)
- Correct
- Partially correct
- Incorrect
- Missed
- No visible abnormal findings
- Swelling
- Visible mass
- Irregular alignment
- Discoloration
- Joint deformity
- No visible abnormal findings
- Swelling
- Visible mass
- Irregular alignment
- Discoloration
- Joint deformity
- No abnormal findings
- Tenderness
- Warmth
- Erythema
- Edema
- No abnormal findings
- Tenderness
- Warmth
- Erythema
- Edema
- No pitting
- 1+ Slight pitting
- 2+ Deeper pit, disappears in 10-15 seconds
- 3+ Noticeably deep pit that lasts for more than a minute
- 4+ Very deep pit that lasts 2 to 5 minutes
- No pitting
- 1+ Slight Pitting
- 2+ Deeper pit, disappears in 10-15 seconds
- 3+ Noticeably deep pit that lasts for more than a minute
- 4+ Very deep pit that lasts 2 to 5 minutes
Education & Empathy
- Opportunities marked as Not Encountered are opportunities that were not elicited in the interview
- Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were made
- Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient
- Liam Fitzgerald Telehealth Follow Up Sick Visit: Management of Cardiovascular Conditions Patient Objective Data Collection
|
Description: Mr. Fitzgerald is experiencing swelling and rapid weight gain. |
||
 |
Any weight issues? (Clarified to: Have you lost weight?) |
Question |
 |
No, I’ve actually gained some. (Clarified to: if I have lost weight) |
|
|
Gaining weight will only worsen your heart problems |
Educate |
|
Got it. Thanks. |
|
|
Model Statement: “You should be aware of what signs and symptoms may indicate worsening heart failure so that you can react appropriately if they arise. For example, the rapid weight gain you experienced over the last 24 hours, or the swelling you are exhibiting in your lower extremities, indicates a fluid volume overload in your body and that your congestive heart failure is worsening. Paying attention to these signs and symptoms can help you determine if you need to take your diuretic. However, if you have continued swelling and weight gain, you should contact your provider and seek emergency hospital care, as they are indications of a CHF exacerbation.” |
|
Description: Mr. Fitzgerald has experienced signs and symptoms that indicate he should use his as needed medications, furosemide and potassium chloride. |
||
|
Model Statement: “You should take your furosemide 20 mg and potassium chloride tablet 10 mEq as needed when you exhibit abnormal signs and symptoms, like swelling and weight gain. Even though the swelling you are experiencing in your lower extremities is minor, it can still have a great affect on your cardiovascular functioning. Taking the furosemide and potassium chloride tablets upon the onset of swelling will help control this symptom and maintain your cardiovascular health. However, if your symptoms worsen or do not resolve, you should contact your provider and seek emergency hospital care.” Liam Fitzgerald Telehealth Follow Up Sick Visit: Management of Cardiovascular Conditions Patient Objective Data Collection |
|
Description: Mr. Fitzgerald recently consumed a meal of high-sodium foods at his grandson’s party. |
||
|
Model Statement: “It can be hard to adhere to your low-sodium diet all the time, especially in social situations. However, nonadherence to your typical low-sodium diet can have negative effects for your cardiovascular health and exacerbate your congestive heart failure. The large quantity of high-sodium foods you ate at the recent party lead to a fluid volume overload and resulted in your rapid weight gain and the swelling in your extremities. Adhering to your diet will help prevent fluctuations in your cardiovascular health and reduce the risk of exacerbating your CHF.” |
|
Description: Mr. Fitzgerald has been experiencing nocturia four to five nights a week. |
||
|
Any urination issues? |
Question |
|
No issues with going to the bathroom, but I do wake up needing to pee at night. |
|
|
Any weakness? |
Question |
|
I’m no Thor, but I can still open pickle jars when needed. |
|
|
Any breathing problems? |
Question |
|
I haven’t had any issues with my breathing. |
|
|
Model Statement: “I’m sorry to hear your sleep has been disrupted by having to wake up frequently to use the bathroom. Having a restful, uninterrupted sleep is important for your physical and emotional health, and disruptions to this can be very irritating. If you need to take your diuretic, do so in the morning if appropriate to avoid triggering nocturia. If your nocturia worsens, follow-up with your provider as it may be an indication of an underlying or worsening condition.” Liam Fitzgerald Telehealth Follow Up Sick Visit: Management of Cardiovascular Conditions Patient Objective Data Collection Dont wait until the last minute.Provide your requirements and let our native nursing writers deliver your assignments ASAP. |