Hispanic-5’ 9” 165-lb Chief complaint= Heart
pounding=What is your name? Joseph Martinez
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.