Shadow Health Tina Jones Cardiovascular Documentation Assignment

Cardiovascular Results | Turned In Nursing 562/562L Advanced Health Assessment – Spring 2021, N562

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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

Document: Provider Notes

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2/15/2021 Cardiovascular | Completed | Shadow Health

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Student Documentation Model Documentation

Subjective

Mr Jomes ios a 28-year old african american femal presentign with 3-4 eposodes of her heart, “beatign too fast” for 5 to 10 minutes per episode over the last month. She describes the palpitations as a “thumping” in her chest, that makes her feel anxious and uncomfortable. The episodes anre not associated with a specific activity, but has noticed it occurs on her way to class in the mnorning. She denies any chest pain and states the palpitations resolve when she calms down and breathes.She states this is the first time she has had any heart trouble, and denies any previous cardiac testing or surgeries. Pt states she is allergic to cats and dust, which can trigger her asthma. She is compliant with her asthma dmedications and has not experienced a recent attack. Patient is allergic to penicillin, denies allergy to latex or foods. Pt takes flovent and proventil for her asthma and denies other medications of suppliments.

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Diagnosed with diabetes a few years ago. She states she has been stressed lately with work at a copy center as a suprvisor and school. She reports a typical diet and consumes about 4 diet cokes and and energy drink or two in the morning. She attributess feeling tired to school and work. She is comfortanle with her current weight, and reports no weight changes. denise fever, chills, dizzyness, reports known hypertension not controlled by medication, no murmurs , experiences ocassional dyspnea on exertion climbing stairs or when hurrying. She reports one recent hospitalization for a foot injury.

Ms. Jones is a pleasant 28-year-old African American woman wh 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 these episodes as “thumping in her chest” with a heart rate that “way faster than usual”. She does not associate the rapid heart r with a specific event, but notes that they usually occur about onc per week in the morning on her commute to class. The episodes generally last between 5 and 10 minutes and resolve spontaneou 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 associa anxiety regarding her rapid heart rate. She denies shortness of breath.

She denies any association of symptoms with exertion. S has no known cardiac history and has never had episodes prior t this last month. She has not attempted any treatment at home an states that she is only coming to the clinic today because her fam 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 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.

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Breakfast is usually a muffi or pumpkin bread, lunch is a sandwich, dinner is a homemade m of a meat and vegetable, snacks are French fries or pretzels. Ove the past month she has increased her consumption of diet soda “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, 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 sh has been told her blood pressure was high in the past. She chec at CVS periodically. At last check it was “140/80 or 90”. She den 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

Ms hjones appears in no acute distress, able to speak in =ull sentences with a wide appropriate variety of vocabulary and is cooperative. She maintaines appropriate eye contact throught the exam and sits with good posture, no ticks or twitches. CV: PMI is brisk and tapping, 2 cm diameter, HR RRR s1 s2 present, no murmurs rubs gallops clicks. All pulses +2 bilaterally without bruits or thrills. No JVD capilary refil <3 sec in all extremities. No peripherial edema. EKG NSR without St elevation or depression or other significant findings. Resp: Chest symmetrical, breathign at ease, regular depth, rise and fall noted. No acessory muscle use or other signs of distress. Breath sounds clear in all fields without advantisious sounds.

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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 2 cm. Regular rate and rhythm, S1 and S2 present, no murmurs, rubs, gallops, clinics, precordial movements. Pulses 2+ and equa bilaterally in upper extremities and lower extremities without thril No temporal, carotid, abdominal aorta, femoral, iliac, or renal bru No JVD. Capillary refill < 3 seconds. No peripheral edema. EKG w 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

Palpitations seem related to caffeine use and or anxiety and stress. Palpitations related to caffeine and/or anxiety

2/15/2021 Cardiovascular | Completed | Shadow Health

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Student Documentation Model Documentation

Plan

Encourage Ms Jones to reduce caffeine use and monitor her signs and symptoms keeping a log. Obtain EKG to rule out abnormalaites Provide education on decreased caffeine consumpton Monitor stress and anxiety levels and consiter mental health referral as needed Provide hypertension and diet education Provide education on what to do if Ms Jones experiences unresolvoing palpitations and or chest pain – call 911 procede to ER. Schedule follow up visit in 4 weeks.

Encourage Ms. Jones to continue to monitor symptoms and log episodes of palpitations with associated factors and bring log to next visit.

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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 inta of water and other fluids.
Educate on anxiety reduction strategies including deep breathin relaxation, and guided imagery. Continue to monitor and explore need for possible referral to social work/psychiatry or pharmacol intervention.
Discuss the need to maintain a stable blood pressure. Encoura Ms. Jones to continue to monitor her blood pressure when a cuff machine is available.
Educate Ms. Jones on when to seek emergent care including episodes of chest pain unrelieved by rest, palpitations that do no dissipate after anxiety related strategies were implemented, chan 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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