Shadow Health Anxiety John Larsen
ED Nursing Note
Student
Model Documentation
Response
Chief (No Mr. Larsen is a 48-year-old White man who presented to the ED
Complaint Documentation at 6 AM with a perceived cardiac complaint; he reports being
Made) exhausted, scared and unable to relax from last night.
History of (No Hx of HTN, hyperlipidemia, and osteoarthritis, presented in the
Present Documentation ED this morning with complaints of exhaustion, anxiety, terror,
Illness Made) and tachycardia which started last night 3 AM. Patient reports
that the worry has been around since he was diagnosed with
HTN (a year ago), but becomes worse last night. He states that
he feels like he is choking, his body is sweating, shivering and
he has been unable to control his fear since 3 AM. He says that
he is scared about everything, especially his hypertension; he
tried to take a deep breath several times to feel calm but did
not work. He states that he came to the ED because he thought
he was having a heart attack from his hypertension. He says
that the anxiety causes him to skip work, prevents social
interaction and that it affects his concentration and sleeping
patterns. He denies any chest pain, fever, mood changes, or
suicidal thoughts.
Allergies (No Codeine
Documentation
Made)
Past Medical (No HTN since age 47 Osteoarthritis since age 46 Hyperlipidemia
History Documentation since age 45
Made)
Past Surgical (No Total knee replacement age 48
History Documentation
Made)
Medication (No Atorvastatin 20 mg P.O. daily for high cholesterol. Last dose:
History Documentation yesterday Lisinopril 10 mg P.O. daily for hypertension. Last
Made) dose: yesterday Fish oil 1 tab daily for high cholesterol. Last
dose: yesterday
Family History (No Mother, living, high cholesterol Father died of lung cancer, had
Documentation HTN, deceased age 50 No known family history of mental
Made) illness
This study source was downloaded by 100000847795904 from CourseHero.com on 05-26-2022 22:08:36 GMT -05:00
https://www.coursehero.com/file/60256851/Shadow-Health-Focused-Exam-Anxiety-John-Larsendocx/
ED Nursing Note
Student
Model Documentation
Response
Chief (No Mr. Larsen is a 48-year-old White man who presented to the ED
Complaint Documentation at 6 AM with a perceived cardiac complaint; he reports being
Made) exhausted, scared and unable to relax from last night.
History of (No Hx of HTN, hyperlipidemia, and osteoarthritis, presented in the
Present Documentation ED this morning with complaints of exhaustion, anxiety, terror,
Illness Made) and tachycardia which started last night 3 AM. Patient reports
that the worry has been around since he was diagnosed with
HTN (a year ago), but becomes worse last night. He states that
he feels like he is choking, his body is sweating, shivering and
he has been unable to control his fear since 3 AM. He says that
he is scared about everything, especially his hypertension; he
tried to take a deep breath several times to feel calm but did
not work. He states that he came to the ED because he thought
he was having a heart attack from his hypertension. He says
that the anxiety causes him to skip work, prevents social
interaction and that it affects his concentration and sleeping
patterns. He denies any chest pain, fever, mood changes, or
suicidal thoughts.
Allergies (No Codeine
Documentation
Made)
Past Medical (No HTN since age 47 Osteoarthritis since age 46 Hyperlipidemia
History Documentation since age 45
Made)
Past Surgical (No Total knee replacement age 48
History Documentation
Made)
Medication (No Atorvastatin 20 mg P.O. daily for high cholesterol. Last dose:
History Documentation yesterday Lisinopril 10 mg P.O. daily for hypertension. Last
Made) dose: yesterday Fish oil 1 tab daily for high cholesterol. Last
dose: yesterday
Family History (No Mother, living, high cholesterol Father died of lung cancer, had
Documentation HTN, deceased age 50 No known family history of mental
Made) illness
This study source was downloaded by 100000847795904 from CourseHero.com on 05-26-2022 22:08:36 GMT -05:00
https://www.coursehero.com/file/60256851/Shadow-Health-Focused-Exam-Anxiety-John-Larsendocx/
