Cardiovascular Completed Shadow Health PDF

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Cardiovascular | Completed | Shadow Health

https://app.shadowhealth.com/assignment_attempts/8491412

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Cardiovascular Results | Turned In Advanced Health Assessment Cases - N678 - September 2020, n678l_clinical_practicum_i Return to Assignment (/assignments/407302/ )

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Documentation / Electronic Health Record

Transcript Subjective Data Collection

Document: Provider Notes

Objective Data Collection Education & Empathy Documentation

Document: Provider Notes Student Documentation

Model Documentation

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11/24/20, 3:24 PM

Cardiovascular | Completed | Shadow Health Student Documentation

Subjective 28-year-old female African American came in to the clinic with complains of intermittent fast heart beat, which started a month ago. It happens once a week for the past month. Patient indicated that heart beat feels like a thumping in her chest, which makes her anxious and uncomfortable. The symptom happens on her way to school in the mornings, right after she drinks her energy drinks. She did not take any OTC medication. She tries to relieve the symptom with relaxation and breathing exercises. Drug Allergies: Penicillin Food Allergies: None Environmental Allergies: Cats and Dust Medication: Flovent 2 puffs twice daily, Proventil 2 puffs as needed for SOB Diet: Regular Appetite: Good Caffeine Intake: Four diet cokes per day 1-2 energy drink Exercise: No Smoke: Never Alcohol: Occasional Drugs: Tried marijuana Cardiovascular: Denies any chest pain, leg swelling, or dyspnea on exertion. Family history: Positive for cardiovascular disease, grandfather, deceased, MI

https://app.shadowhealth.com/assignment_attempts/8491412 Model Documentation

Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of 3-4 episodes of rapid heart rate over the last month. She is a good historian. She describes these episodes as “thumping in her chest” with a heart rate that is “way faster than usual”. She does not associate the rapid heart rate with a specific event, but notes that they usually occur about once per week in the morning on her commute to class. The episodes generally last between 5 and 10 minutes and resolve spontaneously. She does not know her normal heart rate or her heart rate during these episodes. 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. She denies any association of symptoms with exertion. She has no known cardiac history and has never had episodes prior to this last month. She has not attempted any treatment at home and states that she is 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 and is a student at Shadowville Community College. She states that she has been feeling more “stressed” lately due to her school and work. 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 been drinking as much water as her normal. Breakfast is usually a muffin or pumpkin bread, lunch is a sandwich, dinner is a homemade meal of a meat and vegetable, snacks are French fries or pretzels. Over the past month she has increased her consumption of diet soda and “energy” drinks due to her feelings of tiredness. She generally drinks 2 energy drinks before class to “keep her focused” but states that they also make her “jittery”. She denies use of tobacco, alcohol, and 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 night sweats. She complains of intermittent dizziness. • Cardiac: Denies a diagnosis of hypertension, but states that she has been told her blood pressure was high in the past. She checks it at CVS periodically. At last check it was “140/80 or 90”. She denies known history of murmurs, angina, previous palpitations, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or edema. She 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 was 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.

• General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination.

Objective Cardiovascular: PMI non-displaced, no thrills or heaves, RRR, S1S2 with no S3 or S4, murmurs, rubs, or gallops. Elevated blood pressure

• Cardiovascular: PMI is non-displaced, brisk and tapping, diameter 2 cm. Regular rate and rhythm, S1 and S2 present, no murmurs, rubs, gallops, clinics, precordial movements. Pulses 2+ and equal bilaterally in upper extremities and lower extremities without thrills. No temporal, carotid, abdominal aorta, femoral, iliac, or renal bruits. No JVD. Capillary refill < 3 seconds. No peripheral edema. EKG with regular sinus rhythm, no ST changes. ABI is 0.97. • Respiratory: Chest is symmetrical with respirations; no physical abnormalities present on chest wall. Lung sounds clear to auscultation without wheezes, crackles, or cough.

Assessment Differential diagnoses 1: Primary hypertension 2. Dysrythmia 3. Secondary hypertension due to aldosteronism 4. Secondary due to onstructive sleep apnea

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Palpitations related to caffeine and/or anxiety

11/24/20, 3:24 PM

Cardiovascular | Completed | Shadow Health Student Documentation

Plan Plan: Holter monitor for 2 weeks Refer for sleep study Labs: CBC, CMP, TSH, thyroid panel, lipid panel, aldosterone level, renin assay blood test, aldosterone/renin ratio, hgba1c, Urinalysis, Urinary aldosterone Prescription: Start with Amlodipine 2.5 mg 1 tab orall once per day Educate regarding the importance of heatlhy lifestyle such as healthy diet (low salt and low fat diet), weight loss, less caffeine intake, increase exercise, medication adherence and stress management. Go to ER if you experience chest pain, and shortness of breath Return to clinic in 2 weeks for evaluation of clinical improvement. If not improved, medication adjustment will be warranted.

https://app.shadowhealth.com/assignment_attempts/8491412 Model Documentation

Encourage Ms. Jones to continue to monitor symptoms and log her episodes of palpitations with associated factors and bring log to next visit. • Obtain EKG to rule out any cardiac abnormality and assess for symptom-correlated EKG changes. If inconclusive, consider ambulatory EKG monitoring and referral to cardiology. • Encourage to decrease caffeine consumption and increase intake of water and other fluids. • Educate on anxiety reduction strategies including deep breathing, relaxation, and guided imagery. Continue to monitor and explore the need for possible referral to social work/psychiatry or pharmacologic intervention. • Discuss the need to maintain a stable blood pressure. Encourage Ms. Jones to continue to monitor her blood pressure when a cuff or machine is available. • Educate Ms. Jones on when to seek emergent care including episodes of chest pain unrelieved by rest, palpitations that do not dissipate after anxiety related strategies were implemented, changes in vision, loss of consciousness, and sense of impending doom. • Revisit clinic in 2-4 weeks for follow up and evaluation.

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