JPNAOMISTUVIA REVIEW
Joseph Martinez 48 year old male Hispanic
5’ 9” 165 lb
Chief complaint: Heart pounding
What is your name? Joseph Martinez
How can I help you today? (good 1) Oh, boy. My heart’s been pounding over the last 3 days
Any other symptoms we should discuss? (good 2) Yeah. I’m tired out and kind of short of breath.
Tell me about any current or past medical problems. (good 3) Well I have high blood pressure and
elevated cholesterol, but that’s about it.
Do you have any recent acute or chronic infections? uh…no
Have you had chicken pox, shingles, or rheumatic fever? no
What are the events surrounding the start of palpitations? (good 4) Nothing really. Nothing out of the
ordinary
Does anything make your palpitations better or worse? (good 5) Yeah, it gets worse when I climb the
stairs.
Do you have any pain or other symptoms associated with your palpitations? I just feel kind of tired
How severe are your palpitations? (good 6) I don’t know how to judge that, but I’m tired and its
concerning
Do your palpitations keep you from sleeping? I feel my heart pounding in my ears when I lie down, but
I’ve been sleeping without any problem
Have you had palpitations like this before? No, never
Do your palpitations come and go? (good 7) No, its been there continuously since it started
How often do you have palpitations? I’ve never had it before
What treatments have you had for your palpitations? Nothing. Do you have something that will fix it?
Do you have a dizziness problem? Nope
Do you drink alcohol? (good 8) Not much. I’m kind of a lightweight, which is probably a good thing when
you’re in sales. I don’t drink any more than 2 times per month.
Do you use recreational drugs? (good 9) No, Ive always stayed away from anything like that
Do you now or have you ever smoked or chewed tobacco? (good 10) NO
Do you have any of the following problems: fatigue, difficulty sleeping, unintentional weight loss or gain,
fevers, night sweats? (good 11) I’m a little tired, but none of the rest of that stuff.
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, Do you have any problems with headaches that don’t go away with aspirin or Tylenol, double or blurred
visions, difficulty with night vision, problems hearing, ear pain, sinus problems, chronic sore throats,
difficulty swallowing? (good 12) Nope
Do you experience chest pain discomfort or pressure, pain/pressure/dizziness with exertion or getting
angry, palpitations, decreased exercise tolerance, blue/cold fingers and toes? (good 13) Well im here for
the pounding heartbeats. Is that what you call palpitations? I don’t have blue fingers. Now what else was
it you asked?
Do you experience shortness of breath, wheezing, difficulty catching your breath, chronic cough, sputum
production? Yes, some stuff with my feeling short of breath. What all do you want to know about?
Does your chest feel tight or heavy? No, not really
Do you have any of the following: dizziness, fainting, spinning room, seizures, weakness, numbness,
tingling, tremor? (good 14) No spinning or numbness or tingling. I would call it weakness so much as
dragging a bit. Tired you know. I’ve never passed out in my life. Now what else was it you wanted to
know?
Do you have any problems with itchy scalp, skin changes, moles, thinning hair, brittle nails? (good 15) No
Do you have problems with muscle or joint pain, redness, swelling, muscle cramps, joint stiffness, joint
swelling or redness, back pain, neck or shoulder pain, hip pain? (good 16) No
Have you noticed any bruising, bleeding gums, nose bleeds or other sites of increased bleeding? (good
17) No
Do you have any of the following: heat or cold intolerance, increased thirst, increased sweating, frequent
urination, change in appetite? (good 18) no
Do you have any problems with nervousness, depression, lack of interest, sadness, memory loss, or
mood changes, or ever heard voices or see things that you know are not there? (good 19) No, I’m a
pretty easy-going guy. I don’t think this is all in my head.
When you urinate, have you noticed: pain, burning, blood, difficulty starting or stopping, dribbling,
incontinence, urgency during day or night or any changes in frequency? (good 20) NO
Do you have any problems with nausea vomiting, constipation, diarrhea, coffee grounds in your vomit,
dark tarry stool, bright red blood in your bowel movements, early satiety, bloating? (good 21) No
Do you drink caffeinated beverages or eat chocolate? (good 22) I limit myself to 2 cups of coffee a day
Are you taking any prescription medications? (good 23) None at all. Just treating my blood pressure and
cholesterol through lifestyle modification, as my doc calls it. You know, like exercise and watching what I
eat.
Are you taking any OTC or herbal medications? (good 24) No, I stay away from medications as much as
possible. Don’t even take anything when I have a cold
Do you have any allergies? (good 25) I don’t think so
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