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Tina - Results from the Shadow Health Assignment: Cardiovascular: Tina Jones. Including
Advanced Health Assessment (NURS612)
Maryville University
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Cardiovascular Results | Completed
Advanced Health Assessment - MU - May 2022, nurs_612_2w_22/su
Return to Assignment (/assignments/648205/)
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Documentation / Electronic Health Record
Document: Provider Notes
Student Documentation Model Documentation
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Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Lifespan
Review Questions
Self-Reflection
Document: Provider Notes
Student Documentation Model Documentation
Subjective
"Heart seems to be beating way too fast" Occuring for about a month. More often occurs on her way to school. Recent use of energy drinks to assist with focus for school. Daily energy drink use, occasionally will have two. Drink of choice is Turbo Fuel. Denies chest pain. "Throbbing or thumping feeling". Denies SOB. Has had increased stress/anxiety lately related to school and work. Endorses blury vision changes over past year.
Endorses weekly headaches associated with long bouts of reading.
Fam Hx = Mother (HLD,HTN), Father (HTN,HLD, DMII), Sister (Asthma), Brother (Overweight), Maternal grandmother (HTN, HLD), Maternal grandfather (HTN,HLD), Paternal grandmother (HLD,HTN), Paternal grandfather (HTN, DMII, colon CA).
Allergies to penicillin Environmental allergies to cats and dust
Ms. Jones is a pleasant 28-year-old African American woman w presented to the clinic with complaints of 3-4 episodes of rapid rate over the last month. She is a good historian. She describes episodes as <thumping in her chest= with a heart rate that is <wa faster than usual=. She does not associate the rapid heart rate specific event, but notes that they usually occur about once per in the morning on her commute to class. The episodes general between 5 and 10 minutes and resolve spontaneously. She doe know her normal heart rate or her heart rate during these episo 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. denies any association of symptoms with exertion. She has no cardiac history and has never had episodes prior to this last mo She has not attempted any treatment at home and states that s only coming to the clinic today because her family has express concern regarding these episodes.
Social History: Ms. Jones has a job at a copy and shipping stor is a student at Shadowville Community College. She states tha has been feeling more <stressed= lately due to her school and w She has been feeling tired at the end of the day. She denies an specific changes in her diet recently, but notes that she has not drinking as much water as her normal. Breakfast is usually a m pumpkin bread, lunch is a sandwich, dinner is a homemade me meat and vegetable, snacks are French fries or pretzels. Over past month she has increased her consumption of diet soda an <energy= drinks due to her feelings of tiredness. She generally d 2 energy drinks before class to <keep her focused= but states th they also make her <jittery=. She denies use of tobacco, alcoho 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 sweats. She complains of intermittent dizziness.
- Cardiac: Denies a diagnosis of hypertension, but states that s been told her blood pressure was high in the past. She checks CVS periodically. At last check it was <140/80 or 90=. She denie known history of murmurs, angina, previous palpitations, dyspn exertion, orthopnea, paroxysmal nocturnal dyspnea, or edema. has never had an EKG.
- Respiratory: She denies shortness of breath, wheezing, coug sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization w 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
class 2 adult obesity with BMI of 30. Suspected uncontrolled DMII w/ random POCT BG of 224. HR stable and normal currently at 89. Slightly hypertrnsive at 140/81. ABI = 09 = borderline ischemia EKG = SR
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, diam cm. Regular rate and rhythm, S1 and S2 present, no murmurs, gallops, clinics, precordial movements. Pulses 2+ and equal bilaterally in upper extremities and lower extremities without thr temporal, carotid, abdominal aorta, femoral, iliac, or renal bruits JVD. Capillary refill < 3 seconds. No peripheral edema. EKG w regular sinus rhythm, no ST changes. ABI is 0.
Respiratory: Chest is symmetrical with respirations; no physic abnormalities present on chest wall. Lung sounds clear to auscultation without wheezes, crackles, or cough.
Assessment
Systems negative aside from a borderline low ABI
Palpitations related to caffeine and/or anxiety
Tina - Results from the Shadow Health Assignment: Cardiovascular: Tina Jones. Including
Course: Advanced Health Assessment (NURS612)
University: Maryville University
