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Shadow Health Focused Exam – Anxiety: John Larsen – Complete Patient Interaction and Clinical Notes Summary

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This document provides a detailed summary of the Shadow Health virtual patient encounter focused on anxiety, featuring the case of John Larsen. It includes all key subjective and objective findings, clinical reasoning, documentation notes, and therapeutic communication examples. Ideal for nursing students preparing for virtual simulations or clinical assessment documentation practice.

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Voorbeeld van de inhoud

All Li nes (128) Intervi ew Questi ons (65)Statem ents (5) Exam Actions (58)




Greet
Hello, my name is ….. and I am the nurse that will be taking care of
04/02/22 1:33
you this morning PM CDT


Hey . . .

Question
what brings you in today 04/02/22 1:33
PM CDT
I came in here early this morning feeling like I was being smothered,
like I might be having a heart attack or something was going on with
my blood pressure. It was this sort of . . . pressure in my chest. I
guess the docs are chalking it up to panic, but it felt pretty damn real
to me.
Question
Are you still having pressure in your chest? 04/02/22 1:34
PM CDT


I haven't had any fever recently.

Question
What were you doing when this chest pressure started? 04/02/22 1:35
PM CDT
I've had some milder sensations like this over the past year or so, but
it's been getting noticeably worse the past six months. It's never been
as bad as it was this morning thoughthose started around 3 AM. I
guess theyre calling it panic, but I felt like I was having a heart
attack.
Question
were you sleeping when the pain began? (No matching questions
04/02/22 1:35
found.) PM CDT
Question
were you sleeping when this started? 04/02/22 1:36
PM CDT
I've had some milder sensations like this over the past year or so, but
it's been getting noticeably worse the past six months. It's never been
as bad as it was this morning thoughthose started around 3 AM. I

,guess theyre calling it panic, but I felt like I was having a heart
attack.
Empathize
Okay, we are going to figure out what is going on here today. 04/02/22 1:36
PM CDT


Thank you.

Question
Do you have any past medical history 04/02/22 1:36
PM CDT
Yeah, I've got a few . . . I've mostly been worried about my
hypertension and this smothering sensation I had this morning. Other
than that, I've got my high cholesterol and this knee problem . . .
osteoarthritis.
Question
04/03/22
How long did your chest pressure last?
11:36 AM
CDT
I had some milder sensations like this over the past year or so, but it's
been getting noticeably worse the past six months. It's never been as
bad as it was this morning though. I guess they're calling it panic, but
I felt like I was having a heart attack.
Question
04/03/22
what makes it worse?
11:37 AM
CDT
It's as if any little thing can make it worse. Sudden movements,
getting up to walk around definitely makes the sensation worse. I
can't seem to do anything but sit and worry whether or not I'm going
to make it.
Question
04/03/22
does anything make it better? 11:37 AM
CDT

If I take some time to breathereally focus on the fact that I'm still
breathingthat seems to help.

, Question
04/03/22
what makes you worry?
11:37 AM
CDT

I guess I've just been more worried about my health and work than
usual, more so than I've ever been. It feels out of control.

Question
04/03/22
How have you been sleeping?
11:37 AM
CDT
I've never had problems with sleep in the past, but lately I've noticed
it's harder for me to fall asleep. Probably in the past six months or so
...
Question
04/03/22
How have you been eating?
11:38 AM
CDT
I usually have cereal in the morning, maybe with a glass of OJ. For
lunch, I pack some sort of sandwich, usually ham. For dinners, I
usually pop a TV dinner in the oven, usually something with chicken
or beef.
Question
04/03/22
Have you ever been diagnosed with anxiety before?
11:38 AM
CDT
Anxiety's never been a problem in the past, but I guess they are
saying it might be related to these smothering sensations I've been
havinglike I was having a panic attack.
Question
04/03/22
Have you ever been diagnosed with depression?
11:38 AM
CDT

Not depression, no.

Question
04/03/22
Any problems with substance abuse or alcohol? 11:39 AM
CDT

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