NUR 6111 Liam Fitzgerald Shadow Health Telehealth Follow Up Sick Visit: Management of, Exams of Nursing

Download NUR 6111 Liam Fitzgerald Shadow Health Telehealth Follow Up Sick Visit: Management of and more Exams Nursing in PDF only on Docsity!

NUR 6111 Liam Fitzgerald

Shadow Health Telehealth

Follow Up Sick Visit:

Management of

Cardiovascular Conditions

Results Turned In | 2026

Update with complete

solutions..

PATIENT INFORMATION

• Patient Name: Liam Fitzgerald
• Encounter Date: [Current Date]
• Encounter Type: Telehealth Follow-up (Sick Visit)
• Time: [Time of Visit] SUBJECTIVE (S) Chief Complaint: "I'm doing well, but I've noticed my socks leave indentations on my ankles." History of Present Illness (HPI): Mr. Fitzgerald is a patient with a history of chronic congestive heart failure (CHF) presenting for a scheduled telehealth follow-up. He reports general well-being but endorses recent-onset swelling in his feet and ankles. He describes the swelling as significant enough that his socks leave indentations on his skin (pitting edema). He also reports a recent weight gain of 4-5 lbs. He admits to an increase in dietary sodium consumption. He denies any associated dyspnea, orthopnea, cough, wheezing, or chest pain. Review of Systems (ROS):
• General: Denies fatigue (though implied in diagnosis), denies fever.
• Cardiovascular: Denies chest pain, denies palpitations.
• Respiratory: Denies shortness of breath, denies cough, denies wheezing.
• Integumentary: Reports swelling in feet/ankles with sock indentations (pitting edema).
• Gastrointestinal: Denies nausea or vomiting. Past Medical History (PMH):

• Chronic Congestive Heart Failure (CHF) with diastolic dysfunction Medications:
• Prescribed heart failure medications (specific drugs not listed in interview data, but noted as "already prescribed" in treatment plan). Social History:
• Reports limiting sodium intake, though recent increase noted. OBJECTIVE (O) Vital Signs (Patient-reported):
• Reports taking vitals daily at the same time. No issues with equipment reported.
• Note: Specific BP/HR values not captured in interview text, though documentation states "elevated diastolic and systolic pressures" are part of the confirming evidence for the diagnosis. Telehealth/Remote Assessment:
• General Appearance: Alert, oriented, appears stated age, in no acute distress per reported status.
• Cardiovascular: Patient denies chest pain or palpitations.
• Respiratory: Clear to auscultation (implied by denial of cough/wheezing/SOB).
• Integumentary: Patient reports visible swelling in bilateral lower extremities with sock indentations (consistent with pitting edema). ASSESSMENT (A)

Education & Follow-up:

• Dietary: Reinforce strict low-sodium diet (<2,000 mg/day). Discuss specific sources of hidden sodium.
• Monitoring: o Continue daily weights at the same time, on the same scale, wearing the same clothes. o Red Flag Warning: Instruct patient to call the clinic if weight increases by more than 2-3 lbs in 24 hours or 5 lbs in a week, or if shortness of breath develops.
• Follow-up: Schedule follow-up visit in 1 week or sooner if symptoms worsen. Telehealth Protocol (Setup Phase) The interview must begin with essential telehealth compliance steps : Required Question Patient Response Asked patient if they are in an appropriate Confirms they are in a space where the environment for a visit visit can be conducted Asked if they can hear provider Confirms they are able to hear provider Inform patient this is a confidential Acknowledges awareness of protected visit confidentiality Pro Tip: Telehealth visits require specific considerations to maintain standards of practice: asking about private space, confidentiality, and audio/visual accessibility issues.

Episodic Heart Failure Questionnaire (Assessment Phase) General Wellbeing & Vital Signs Question Patient Response Asked how patient is doing Reports doing well Asked about taking vital signs Reports taking vitals daily Reports taking vitals at same time each day Respiratory Assessment Reports no problems with equipment Symptom Patient Response Cough Denies cough Wheezing Denies wheezing Shortness of breath Denies any trouble breathing Cardiovascular Assessment

Breakfast Typical breakfast as reported Lunch Salad with pasta and grilled [chicken] Pain status Denies pain (self-reported) Negative Findings (Reassuring) Finding Significance Clinical Findings Summary Positive Findings (Concerning) Finding Clinical Significance Weight gain 4-5 lbs Suggests fluid retention; >2-3 lbs in 24 hrs or 5 lbs 1 week is a heart failure red flag Swelling in feet/ankles with sock indentations Indicates pitting edema from fluid volume overloa Fatigue with activity Symptom of worsening heart failure Increased sodium consumption Contributes to fluid retention

No chest pain No acute coronary syndrome No shortness of breath No acute pulmonary edema No cough or wheezing No respiratory decompensation No pain No acute distress Diagnosis and Treatment Plan Primary Diagnosis Fluid volume overload (identified as primary) Supporting Evidences:

• Fatigue with activity
• Pitting edema
• Report of increased sodium consumption
• Weight gain Secondary Diagnosis Acute on chronic congestive heart failure (CHF) with diastolic dysfunction Supporting Evidences:
• Elevated diastolic pressure
• Elevated systolic pressure
• Fatigue with activity
• Pitting edema
• Report of increased sodium consumption
• Weight gain

General & Vitals

• Q: How are you doing? → A: Reports doing well.
• Q: Have you been taking your vital signs daily? → A: Reports taking vitals daily (at the same time each day). Reports no problems with equipment. Respiratory Assessment (Negative Findings)
• Q: Any cough/shortness of breath/wheezing? → A: Denies cough, denies wheezing, denies shortness of breath. Cardiovascular & Fluid Status (Key Positive Findings)
• Q: Any chest pain/palpitations? → A: Denies chest pain, denies palpitations.
• Q: Have you noticed any swelling? → A: Reports swelling (Feet and ankles).
• Q: Describe the swelling. → A: "Socks left indentations" (Indicates pitting edema ).
• Q: Have you noticed a change in your weight? → A: Reports weight gain of 4-5 lbs (Critical red flag for fluid overload). Diet & Pain Required Question Patient Response Pro Tip (Clinical Significance) "Can you hear me ok?" Confirms they are able to hear the provider. Confirms audio/visual functionality to prevent miscommunication. "Have you been informed that this is a confidential protected visit?" Acknowledges awareness of confidentiality. Legally required notification th the visit is HIPAA- compliant an secure.

• Q: How would you describe your typical diet? → A: Reports limiting sodium intake (Salad with pasta/grilled chicken for lunch).
• Q: Are you having any pain? → A: Denies pain. Diagnosis & Clinical Documentation (The "Answer Key") Based on the data above, this is the specific documentation required to get a perfect score on the diagnostic portion of the assignment. Primary Diagnosis
• Diagnosis: Fluid volume overload (Identified as primary).
• Supporting Evidences: Fatigue with activity, Pitting edema, Report of increased sodium consumption, Weight gain. Secondary Diagnosis
• Diagnosis: Acute on chronic congestive heart failure (CHF) with diastolic dysfunction.
• Supporting Evidences: Elevated diastolic pressure, Elevated systolic pressure, Fatigue with activity, Pitting edema, Report of increased sodium consumption, Weight gain. Model Rationale (Use this to write your notes) "Mr. Fitzgerald's primary diagnosis is fluid volume overload, with a secondary diagnosis of acute on chronic congestive heart failure (CHF) with diastolic dysfunction. The fluid volume overload has exacerbated his chronic condition. Mr. Fitzgerald's signs and symptoms of weight gain, pitting edema, fatigue with activity, and self-reported sodium increase have contributed to his fluid volume overload and the