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Cardiovascular Completed Shadow Health sub
Advanced Physical Assessment (NUR634)
Long Island University
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7/4/2021 Cardiovascular | Completed | Shadow Health
app.shadowhealth/assignment_attempts/10113755 1/
Cardiovascular Results | Turned In
Advanced Physical Assessment - May 2021, NUR 634
Return to Assignment (/assignments/493256/)
Subjective Data Collection: 19 of 19 (100%)
Chief Complaint
History of Presenting Illness
Your Results Reopen (/assignment_attempts/10113755/reopen
Lab Pass (/assignment_attempts/10113755/lab_pass
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Student Survey
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Category Scored Items
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Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details are facts of t patient's case.
Established chief complaint Reports recent episodes of palpitations Describes heart rate during episodes as feeling "faster than usual"
Asked about onset Reports first episode a month ago
Asked about frequency and duration of fast heartbeat episodes
Reports episodes occur "about once a week" Reports 3-4 episodes total Reports fast heartbeat episodes last 5-10 minutes
Asked about character of palpitations Describes palpitations as "thumping" or "pounding" Reports episodes accompanied by mild anxiety
Asked about aggravating factors Reports that palpitations seem to occur more often in the morning Reports episodes not exacerbated by exertion Reports that episodes do not occur after eating
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7/4/2021 Cardiovascular | Completed | Shadow Health
app.shadowhealth/assignment_attempts/10113755 2/
Medical History
Social Determinants of Health
Social History
Reports caffeine as a possible aggravating factor
Asked about relieving factors Reports deep breathing and trying to relax Denies medication or other treatment
Confirmed use of medications Confirms medications from previous visit Reports new inhaler
Followed up on new inhaler New inhaler is Flovent Prescribed dose is two puffs Inhaler is prescribed for daily use Describes new inhaler regiment as effective
Confirmed allergies Confirms allergies (no new allergies reported)
Asked about personal history of hypertension Reports usual blood pressure "might be on the high side" Denies past diagnosis of hypertension Does not check BP regularly Is aware of risk factors for hypertension
Asked about possible contributing factors in health history
Reports no known history of heart disease Reports type 2 diabetes Reports no past diagnosis of high cholesterol Reports no history of rheumatic fever Reports no history of heart murmur Reports no EKG or other diagnostic cardiac tests
Asked about stress and anxiety Reports occasional feelings of anxiety Reports recent increase in stress Reports stress related to school and work
Asked about typical diet Breakfast is usually a muffin or pumpkin bread Lunch is usually a sandwich Dinner is usually a home-cooked meat dish and side of vegetables Snacks are pretzels or French fries
Asked about caffeine consumption Reports increased caffeine consumption Reports consuming diet soda or energy drinks Reports caffeine increase was over last month Typical drinks 2 energy drinks before class Reports caffeine "keeps me focused but sometimes makes me jittery"
Asked about exercise and activity level Reports general low activity level
Cardiovascular Completed Shadow Health sub
Course: Advanced Physical Assessment (NUR634)
University: Long Island University
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