Cardiovascular Completed Shadow Health write out PDF

Preview

Summary

Shadow Health...

Description

7/4/2021

Cardiovascular | Completed | Shadow Health

Cardiovascular Results | Turned In Advanced Physical Assessment - May 2021, NUR 634 Return to Assignment (/assignments/493256/)

Your Results

Reopen (/assignment_attempts/10113755/reopen Lab Pass (/assignment_attempts/10113755/lab_pass.p

Overview

Documentation / Electronic Health Record

Transcript Subjective Data Collection

Document: Provider Notes

Objective Data Collection Education & Empathy Documentation

Document: Provider Notes Student Documentation

Model Documentation

Student Survey

Support

https://app.shadowhealth.com/assignment attempts/10113755

1/3

7/4/2021

Cardiovascular | Completed | Shadow Health

Student 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

Model Documentation

Ms. Jones is a pleasant 28-year-old African American woman w presented to the clinic with complaints of 3-4 episodes of rapid h 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 w specific event, but notes that they usually occur about once per in the morning on her commute to class. The episodes generally between 5 and 10 minutes and resolve spontaneously. She doe know her normal heart rate or her heart rate during these episod 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 k 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 expresse 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 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 mu 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 d 2 energy drinks before class to “keep her focused” but states th they also make her “jittery”. She denies use of tobacco, alcohol, 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 n sweats. She complains of intermittent dizziness. • Cardiac: Denies a diagnosis of hypertension, but states that sh been told her blood pressure was high in the past. She checks i 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. 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 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 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, diam cm. Regular rate and rhythm, S1 and S2 present, no murmurs, r gallops, clinics, precordial movements. Pulses 2+ and equal bilaterally in upper extremities and lower extremities without thril temporal, carotid, abdominal aorta, femoral, iliac, or renal bruits JVD. Capillary refill < 3 seconds. No peripheral edema. EKG wit regular sinus rhythm, no ST changes. ABI is 0.97. • Respiratory: Chest is symmetrical with respirations; no physica 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.

https://app.shadowhealth.com/assignment attempts/10113755

Palpitations related to caffeine and/or anxiety

2/3

7/4/2021

Cardiovascular | Completed | Shadow Health

Student Documentation

Model Documentation

Plan Tina can use a referal to practitioner for management o stress and anxiety. This can used to balance her responsibilities. Provide education regarding caridiovascul consitions especially hypertension and hypertension related to diabetes. refer Tina to a dietian for assistance with a diet which cam help her lose weight and prevent hypertension.

Encourage Ms. Jones to continue to monitor symptoms and log episodes of palpitations with associated factors and bring log to visit. • Obtain EKG to rule out any cardiac abnormality and assess fo symptom-correlated EKG changes. If inconclusive, consider ambulatory EKG monitoring and referral to cardiology. • Encourage to decrease caffeine consumption and increase int water and other fluids. • Educate on anxiety reduction strategies including deep breath relaxation, and guided imagery. Continue to monitor and explore need for possible referral to social work/psychiatry or pharmaco intervention. • Discuss the need to maintain a stable blood pressure. Encoura Ms. Jones to continue to monitor her blood pressure when a cuf machine is available. • Educate Ms. Jones on when to seek emergent care including episodes of chest pain unrelieved by rest, palpitations that do n dissipate after anxiety related strategies were implemented, cha in vision, loss of consciousness, and sense of impending doom. • Revisit clinic in 2-4 weeks for follow up and evaluation.

Comments If your instructor provides individual feedback on this assignment, it will appear here.

© Shadow Health® 2012 - 2021 (800) 860-3241 | Help Desk (https://support.shadowhealth.com/) | Terms of Service (/static/terms_of_service) | Privacy Policy ↗ (/static/privacy_policy) | Patents (https://www.shadowhealth.com/patents)

https://app.shadowhealth.com/assignment attempts/10113755

3/3...