Scenario 1
When obtaining a patient’s chief complaint of fatigue and dizziness, you also notice that he is short of breath and is having difficulty breathing. The patient doesn’t mention these symptoms in his chief complaint and talks only about the fatigue and dizziness.

1. What should you do about the apparent symptoms of shortness of breath and dyspnea?





2. Should you chart your observed symptoms with the patient’s chief complaint?





3. Should you discuss this information with the provider?