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Cardiovascular Completed Shadow Health write out
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/)
Documentation / Electronic Health Record
Document: Provider Notes
Student Documentation Model Documentation
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Overview
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Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Student Survey
Document: Provider Notes
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7/4/2021 Cardiovascular | Completed | Shadow Health
app.shadowhealth/assignment_attempts/10113755 2/
Student Documentation Model Documentation
Subjective
Tina Jones presents with episodes of "fast heartbeat" which has been occuring for over a month. The "fast heartbeat" is lo alized t the left enter of her chest. She endorses that she feels no pain however the 'fast heartbeats" mostly occur in the morning before class. TIna states she does not drink coffee and alleviate her palpitations she "tries to slow down". Tina confirms that she has sources of stress and anxiety which are work and school. Tina denies smoking and states she seldomly drinks. Allergies include cats. dust, and penicillin. Medications include Flovent and rescue inhalers. Family History has hypertension, hyperlipidemia, diabete melluitis, and asthma. Tina Jones endorses that she does not really watch her diet
Ms. Jones is a pleasant 28-year-old African American woman wh presented to the clinic with complaints of 3-4 episodes of rapid he rate over the last month. She is a good historian. She describes t episodes as “thumping in her chest” with a heart rate that is “way faster than usual”. She does not associate the rapid heart rate w specific event, but notes that they usually occur about once per w in the morning on her commute to class. The episodes generally between 5 and 10 minutes and resolve spontaneously. She does know her normal heart rate or her heart rate during these episode She denies chest pain during the episodes, but does endorse discomfort of 3/10 which she attributes to associated anxiety regarding her rapid heart rate. She denies shortness of breath. S denies any association of symptoms with exertion. She has no kn cardiac history and has never had episodes prior to this last mon She has not attempted any treatment at home and states that sh only coming to the clinic today because her family has expressed concern regarding these episodes.
Social History: Ms. Jones has a job at a copy and shipping store is a student at Shadowville Community College. She states that s has been feeling more “stressed” lately due to her school and wo She has been feeling tired at the end of the day. She denies any specific changes in her diet recently, but notes that she has not b drinking as much water as her normal. Breakfast is usually a muf pumpkin bread, lunch is a sandwich, dinner is a homemade mea meat and vegetable, snacks are French fries or pretzels. Over th past month she has increased her consumption of diet soda and “energy” drinks due to her feelings of tiredness. She generally dr 2 energy drinks before class to “keep her focused” but states tha they also make her “jittery”. She denies use of tobacco, alcohol, a illicit drugs. She does not exercise.
Review of Systems: General: Denies changes in weight, but complains of end of day fatigue. She denies fevers, chills, and ni sweats. She complains of intermittent dizziness.
- Cardiac: Denies a diagnosis of hypertension, but states that she been told her blood pressure was high in the past. She checks it CVS periodically. At last check it was “140/80 or 90”. She denies known history of murmurs, angina, previous palpitations, dyspne exertion, orthopnea, paroxysmal nocturnal dyspnea, or edema. S has never had an EKG.
- Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization wa age 16 for asthma, last chest XR was age 16.
- Hematologic: She denies history of anemia, easy bruising or bleeding, petechiae, purpura, or blood transfusions.
Objective
General, Tina Jones is a pleasant obese 28 ear old female. Tina Jones is alert and oriented x3 and she is a credible source of her history. Examination findings: Heart rate is is regular and normal. s1 and s2 heard without murmurs or additional sounds. All pulsed with normal range. No thrills are bruit. No EKG chanes.
General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. maintains eye contact throughout interview and examination.
Cardiovascular: PMI is non-displaced, brisk and tapping, diame cm. Regular rate and rhythm, S1 and S2 present, no murmurs, ru gallops, clinics, precordial movements. Pulses 2+ and equal bilaterally in upper extremities and lower extremities without thrill temporal, carotid, abdominal aorta, femoral, iliac, or renal bruits. JVD. Capillary refill < 3 seconds. No peripheral edema. EKG with regular sinus rhythm, no ST changes. ABI is 0.
Respiratory: Chest is symmetrical with respirations; no physical abnormalities present on chest wall. Lung sounds clear to auscultation without wheezes, crackles, or cough.
Assessment
Tina Jones palpitations appear to be related to notable stress and anxiety which is related to the pressures of schools and work. Additionally, Tina needs education in regards to her risks related to cardivascular consitions and/or disease.
Palpitations related to caffeine and/or anxiety
Cardiovascular Completed Shadow Health write out
Course: Advanced Physical Assessment (NUR634)
University: Long Island University
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