A2

New irregular rhythm — suspected AF

Skilled cardiovascular assessment identified a new irregularly irregular pulse not previously documented. Apical pulse auscultated for one full minute at 112, irregular; radial pulse 96, yielding an apical–radial deficit of 16. BP 138/84. Patient reports intermittent palpitations and mild lightheadedness but denies chest pain or syncope. Findings concerning for new-onset atrial fibrillation with rapid ventricular response. Provider notified at 10:20 with the apical rate, rhythm, deficit, and symptoms; order received to obtain an ECG and evaluate, with instruction to escalate for chest pain, syncope, or worsening symptoms. Patient remained hemodynamically stable during the visit and was advised on warning signs requiring 911. Reassessment and follow-up coordinated with the provider.

A3

Chest pain — possible ACS, EMS activated

Patient reported new substernal chest pressure rated 6/10 with associated dyspnea. Findings were concerning for possible acute coronary syndrome. Emergency medical services were activated according to agency protocol. Prescribed sublingual nitroglycerin was administered per the patient-specific order while awaiting EMS, with serial reassessment of pain (6/10 → 4/10), blood pressure, heart rate, oxygen saturation, and symptoms documented. The provider was notified and family present were informed; the patient was kept calm and positioned per the patient-specific order, and the event, communications, and serial vital signs were documented pending transport, with follow-up to coordinate care and reassess on return home.

A4

New or changed murmur — possible valvular change

Skilled cardiovascular assessment identified a new III/VI systolic murmur at the left lower sternal border not documented at prior visits; S1 and S2 otherwise intact, no rub. Heart rate 82 and regular; BP 128/78. Patient reports mild exertional dyspnea but denies chest pain or syncope. Findings represent a new murmur of uncertain significance that may indicate valvular change. Provider notified at 13:20 with the murmur location, intensity, and the new exertional symptom; order received to evaluate, with instruction to escalate for chest pain, syncope, or worsening dyspnea. Patient remained hemodynamically stable during the visit and was advised on symptoms requiring prompt reporting. Reassessment and follow-up coordinated with the provider.

A5

Symptomatic bradycardia — possible medication effect

Skilled cardiovascular assessment found a heart rate of 46 and regular, decreased from the patient's baseline in the upper 50s, with the patient reporting new fatigue and lightheadedness on standing. BP 108/64. No chest pain or syncope. Findings suggest symptomatic bradycardia that may reflect a medication effect. Patient seated safely and fall precautions implemented; the rate-controlling medication dose and timing were reviewed during reconciliation. Provider notified at 10:35 with the heart rate, the change from baseline, and the symptoms; order received to hold the next rate-controlling dose and recheck, with instruction to escalate for syncope, chest pain, or a heart rate below the ordered threshold. The patient's lightheadedness resolved when seated; reassessment of heart rate and symptoms planned next visit.

A6

New tachycardia / palpitations

Patient reported new intermittent palpitations; skilled assessment found a heart rate of 116 and regular at rest, increased from a baseline in the 70s. BP 132/82; SpO2 97% on room air; no chest pain, dyspnea, or syncope. Hydration, recent caffeine or stimulant use, missed or doubled medication doses, and fever were screened. Findings represent new resting tachycardia of uncertain cause. Provider notified at 11:50 with the rate, the change from baseline, and the screening results; order received to obtain an ECG and basic labs and to reassess, with instruction to escalate for chest pain, syncope, or worsening symptoms. Patient remained stable and was advised on warning signs requiring 911. Reassessment and follow-up coordinated with the provider.