Exam (elaborations) NR 509 Cardiovascular Physical Assessment Assignment Completed Shadow Health

Exam (elaborations) NR 509 Cardiovascular Physical Assessment Assignment Completed Shadow Health ocument: Provider Notes Student Documentation Model Documentation Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Lifespan Review Questions Self-Reflection Documentation / Electronic Health Record This study source was downloaded by from CourseH on :46:22 GMT -05:00 This study resource was shared via CourseH 12/10/2018 Cardiovascular Physical Assessment Assignment | Completed | Shadow Health Student Documentation Model Documentation Subjective TJ, 28 years, Female, African American CC: Heart palpitations, "heart beating too fast" HPI: Tina, a 28 year old african american female, came into the clinic with complaints of her "heart beating too fast" and "faster than usual." It started about a month ago when work and school started to become more stressful and busy. She has had 3 to 4 episodes total and the episodes last between 5 and 10 minutes. She described the palpitations as "pounding" or "thumping." She feels anxiety as the symptoms start to appear. She states that the symptoms are worse in the morning, but physical activity or eating do not make them worse. Patient has not attempted any form of treatment for the palpitations. Current medications: Fluticasone 110mcg per 2 puffs daily Albuterol 90mcg per puff, 2 puffs as needed Acetaminophen 500-1000mg as needed for headaches Ibuprofen 600mg as needed for menstrual cramps Allergies: Environmental: Cats, Dust Medication: Penicillen No new allergies since last visit. Medical History: Diagnosed with Asthma and Type 2 Diabetes. Patient denies a diagnosis of high blood pressure, but states that it is on the high side. She does not check it regularly. ER visit for foot wound 3 months ago Past history of hospitilizations for asthma. Last one was many years ago. Patient has no known history of heart disease or high cholesterol. Social History: Patient notes a heightned stress level lately due to work and school. She also has feelings of anxiety. Patient's diet seems to be average. Patient consumes a high amount of caffeine including diet soda and up to two energy drinks a day. Patient does not exercise regulalry. Patient drinks occasionally with the last drink being two weeks ago. Patient does not smoke. Patient does not do drugs. Family History: Family has history of Cornoray Artery Disease, high cholesterol, hypertension, stroke, and obesity. ROS: General: Patient denies any recent illnesses, denies fever, denies nausea, reports low energy. Cardio: Patient denies shortness of breath, chest pain, edema, circulation problems, easy bleeding, and dizziness. 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. This study source was downloaded by from CourseH on :46:22 GMT -05:00 This study resource was shared via CourseH 12/10/2018 Cardiovascular Physical Assessment Assignment | Completed | Shadow Health Student Documentation Model Documentation Objective Tina Jones is an obese 28 year old African American female. She was alert and clear headed. She appeared clean and in good spirits. She answered all questions fully and accurately. Physical exam: Inspection: Chest was symmetric with no abnormal findings. JVD was 4 cm or less above sternal angle. Hands and fingernails had no abnormal findings with capillary refill time of 3 seconds or less. Lower extremeties and toenails showed no edema, no abnormal findings, with capillary refill time of 3 sec or less. Palpation: Temporal arteries had no thrill with 2+ amplitude. Carotid arteries had no thrill with 2+ amplitude. PMI present, brisk and tapping, less than 3cm. Radial arteries had no thrill and an amplitude of 2+. Brachial arteries had no thrill and an amplitude of 2+. Femoral arteries had no thrill with an amplitude of 2+. Popliteal arteries had no thrill and 2+ amplitude. Tibial arteries had no thrill with 2+ amplitude. Dorsalis pedis arteries had no thrill and had 2+ amplitude. Auscultate: Temporal arteries had no bruit. Carotid arteries had no bruit. Breath sounds present and clear in all areas with no adventitious sounds. s1 and s2 heart sounds were audbile with no extra sounds. Abdominal aorta had no bruit, renal arteries had no bruit. Iliac arteries had no bruits. Femoeral arteries had no bruit. Testing: Ankle-brachial index test: 0.972, mildly ischemic EKG: regular, no ST changes • General: Ms. Jones is a pleasant, obese 28-yearold African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination. • 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 Chief diagnosis: Palpitations related to anxiety. Due to the patient's comments that the palpitations started with stress related to school and work, I believe that her palpitations are caused by anxiety. Differential diagnosis: 1. Caffeine induced palpitations: The patient consumes high levels of caffeine, so this could onctribute to her palpitations. 2. Hypertension: Hypertension runs in the family and she had a high reading at this appointment. If her BP stays consistently high and the palpitations continue, this will need to be addressed. Palpitations related to caffeine and/or anxiety This study source was downloaded by from CourseH on :46:22 GMT -05:00 This study resource was shared via CourseH 12/10/2018 Cardiovascular Physical Assessment Assignment | Completed | Shadow Health Student Documentation Model Documentation Plan Diagnostics: EKG to rule out any heart defects or abnormalities. Medications: None Education: I would like Ms. Jones to keep an eye on her symptoms and to log their times and what she was doing at the time so we can try to pinpoint a cause. I educated Ms. Jones on different ways to help manage her anxiety like relaxation and deep breathing techniques. I also educated her on the negative effects of caffeine and encouraged her to drink more water instead of soda and energy drinks. I told her that she should keep an eye on her blood pressure and to check it when she can. I told her that her pressure was on the high side and encouraged her to eat a low sodium diet and to begin a light exercise regimen to keep her heart healthy and her BP down. I also educated her on when she should seek emergency care in the case of chest pain or if her symptoms get significantly worse. Referral: Depending on the results of the EKG, I would refer Ms. Jones to a Cardiologist. If Ms. Jones feels like she needs to talk to someone about her anxiety, I would refer her to a mental health professional. Follow-up: If the patient's symptoms do not worsen after a visit with the cardiologist or mental health professional, I would like to see her as soon as possible, but if her symtpoms resolve, I would like to see her in around 6 months. Diagnostics • 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 Medication • None at this time Education • Encourage Ms. Jones to continue to monitor symptoms and log her episodes of palpitations with associated factors and bring log to next visit • Discuss the need to maintain a stable blood pressure and instruct Ms. Jones to continue to monitor her blood pressure when a cuff or machine is available • 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 Referral/Consultation • Consultation with appropriate mental health professional for counselling, cognitive behavioral therapy, or pharmacologic intervention Follow-up Planning • Instruct 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. Comments Olivia Mgbeokwere (24 Nov 2018, 08:53 PM CST): Dear Student, Congratulations! You did a nice job with this case study. Of course, there is always room for improvement. Please take time to review your results and the feedback provided by Shadow Health. Compare your performance with the model note. It is important to understand where you may have missed opportunities to be more effective or enhance your skills. Be sure to utilize the OLDCART Your HPI is missing pertinent information. Also your ROS/objective data are inadequate..Please document using systems not technique Your differential diagnoses were supported by the presenting facts. However, since Tina presented with palpitations, it is perfectly acceptable to use the symptom "Palpitations" as a primary diagnosis, at least until other etiologies are ruled out. It is important for primary care providers to utilize various resources to support patient care. What advice do you have for her regarding the amount of caffeinated beverages she consumes per day? Finally, be sure to include plans to follow-up and provide specific instructions for when to seek immediate attention. In preparing for debriefing of Week 4, I am going to ask you about potential safety concerns with Tina. Can you identify any in this assignment? Let me know if you have any questions or concerns. This study source was downloaded by