12/10/2018 Cardiovascular Physical Assessment Assignment | Completed | Shadow Health
Cardiovascular Physical Assessment Assignment Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-October-2018
Return to Assignment
Your Results Lab Pass
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Document: Provider Notes
Objective Data Collection
Education & Empathy Document: Provider Notes
Documentation
Student Documentation Model Documentation
Lifespan
Review Questions
Self-Reflection
https://www.coursehero.com/file/36351689/NR-509-Cardiovascular-Documentation-Shadowpdf/
https://chamberlain.shadowhealth.com/assignment_attempts/4221355 1/5
, 12/10/2018 Cardiovascular Physical Assessment Assignment | Completed | Shadow Health
Subjective
Ms. Jones is a pleasant 28-year-old African
TJ, 28 years, Female, African American American woman who presented to the clinic with
complaints of 3-4 episodes of rapid heart rate over
CC: Heart palpitations, "heart beating too fast" the last month. She is a good historian. She
describes these episodes as “thumping in her chest”
HPI: Tina, a 28 year old african american female, with a heart rate that is “way faster than usual”. She
came into the clinic with complaints of her "heart does not associate the rapid heart rate with a
beating too fast" and "faster than usual." It started specific event, but notes that they usually occur
about a month ago when work and school started to about once per week in the morning on her commute
become more stressful and busy. She has had 3 to 4 to class. The episodes generally last between 5 and
episodes total and the episodes last between 5 and 10 minutes and resolve spontaneously. She does
10 minutes. She described the palpitations as not know her normal heart rate or her heart rate
"pounding" or "thumping." She feels anxiety as the during these episodes. She denies chest pain during
symptoms start to appear. She states that the the episodes, but does endorse discomfort of 3/10
symptoms are worse in the morning, but physical which she attributes to associated anxiety regarding
activity or eating do not make them worse. Patient her rapid heart rate. She denies shortness of breath.
has not attempted any form of treatment for the She denies any association of symptoms with
palpitations. exertion. She has no known cardiac history and has
never had episodes prior to this last month. She has
Current medications: not attempted any treatment at home and states that
Fluticasone 110mcg per 2 puffs daily she is only coming to the clinic today because her
Albuterol 90mcg per puff, 2 puffs as needed family has expressed concern regarding these
Acetaminophen 500-1000mg as needed for episodes.
headaches
Ibuprofen 600mg as needed for menstrual cramps Social History: Ms. Jones has a job at a copy and
shipping store and is a student at Shadowville
Allergies: Community College. She states that she has been
Environmental: Cats, Dust feeling more “stressed” lately due to her school and
Medication: Penicillen work. She has been feeling tired at the end of the
No new allergies since last visit. day. She denies any specific changes in her diet
recently, but notes that she has not been drinking as
Medical History: much water as her normal. Breakfast is usually a
Diagnosed with Asthma and Type 2 Diabetes. muffin or pumpkin bread, lunch is a sandwich, dinner
Patient denies a diagnosis of high blood pressure, is a homemade meal of a meat and vegetable,
but states that it is on the high side. She does not snacks are French fries or pretzels. Over the past
check it regularly. month she has increased her consumption of diet
ER visit for foot wound 3 months ago soda and “energy” drinks due to her feelings of
Past history of hospitilizations for asthma. Last one tiredness. She generally drinks 2 energy drinks
was many years ago. before class to “keep her focused” but states that
Patient has no known history of heart disease or they also make her “jittery”. She denies use of
high cholesterol. tobacco, alcohol, and illicit drugs. She does not
exercise.
Social History: Patient notes a heightned stress level
lately due to work and school. She also has feelings Review of Systems: General: Denies changes in
of anxiety. Patient's diet seems to be average. weight, but complains of end of day fatigue. She
Patient consumes a high amount of caffeine denies fevers, chills, and night sweats. She
including diet soda and up to two energy drinks a complains of intermittent dizziness.
day. Patient does not exercise regulalry. Patient • Cardiac: Denies a diagnosis of hypertension, but
drinks occasionally with the last drink being two states that she has been told her blood pressure
weeks ago. Patient does not smoke. Patient does was high in the past. She checks it at CVS
not do drugs. periodically. At last check it was “140/80 or 90”. She
denies known history of murmurs, angina, previous
Family History: Family has history of Cornoray Artery palpitations, dyspnea on exertion, orthopnea,
Disease, high cholesterol, hypertension, stroke, and paroxysmal nocturnal dyspnea, or edema. She has
obesity. never had an EKG.
• Respiratory: She denies shortness of breath,
ROS: wheezing, cough, sputum, hemoptysis, pneumonia,
General: Patient denies any recent illnesses, denies bronchitis, emphysema, tuberculosis. She has a
fever, denies nausea, reports low energy. history of asthma, last hospitalization was age 16 for
asthma, last chest XR was age 16.
Cardio: Patient denies shortness of breath, chest • Hematologic: She denies history of anemia, easy
pain, edema, circulation problems, easy bleeding, bruising or bleeding, petechiae, purpura, or blood
and dizziness. transfusions.
https://www.coursehero.com/file/36351689/NR-509-Cardiovascular-Documentation-Shadowpdf/
https://chamberlain.shadowhealth.com/assignment_attempts/4221355 2/5
Cardiovascular Physical Assessment Assignment Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-October-2018
Return to Assignment
Your Results Lab Pass
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Document: Provider Notes
Objective Data Collection
Education & Empathy Document: Provider Notes
Documentation
Student Documentation Model Documentation
Lifespan
Review Questions
Self-Reflection
https://www.coursehero.com/file/36351689/NR-509-Cardiovascular-Documentation-Shadowpdf/
https://chamberlain.shadowhealth.com/assignment_attempts/4221355 1/5
, 12/10/2018 Cardiovascular Physical Assessment Assignment | Completed | Shadow Health
Subjective
Ms. Jones is a pleasant 28-year-old African
TJ, 28 years, Female, African American American woman who presented to the clinic with
complaints of 3-4 episodes of rapid heart rate over
CC: Heart palpitations, "heart beating too fast" the last month. She is a good historian. She
describes these episodes as “thumping in her chest”
HPI: Tina, a 28 year old african american female, with a heart rate that is “way faster than usual”. She
came into the clinic with complaints of her "heart does not associate the rapid heart rate with a
beating too fast" and "faster than usual." It started specific event, but notes that they usually occur
about a month ago when work and school started to about once per week in the morning on her commute
become more stressful and busy. She has had 3 to 4 to class. The episodes generally last between 5 and
episodes total and the episodes last between 5 and 10 minutes and resolve spontaneously. She does
10 minutes. She described the palpitations as not know her normal heart rate or her heart rate
"pounding" or "thumping." She feels anxiety as the during these episodes. She denies chest pain during
symptoms start to appear. She states that the the episodes, but does endorse discomfort of 3/10
symptoms are worse in the morning, but physical which she attributes to associated anxiety regarding
activity or eating do not make them worse. Patient her rapid heart rate. She denies shortness of breath.
has not attempted any form of treatment for the She denies any association of symptoms with
palpitations. exertion. She has no known cardiac history and has
never had episodes prior to this last month. She has
Current medications: not attempted any treatment at home and states that
Fluticasone 110mcg per 2 puffs daily she is only coming to the clinic today because her
Albuterol 90mcg per puff, 2 puffs as needed family has expressed concern regarding these
Acetaminophen 500-1000mg as needed for episodes.
headaches
Ibuprofen 600mg as needed for menstrual cramps Social History: Ms. Jones has a job at a copy and
shipping store and is a student at Shadowville
Allergies: Community College. She states that she has been
Environmental: Cats, Dust feeling more “stressed” lately due to her school and
Medication: Penicillen work. She has been feeling tired at the end of the
No new allergies since last visit. day. She denies any specific changes in her diet
recently, but notes that she has not been drinking as
Medical History: much water as her normal. Breakfast is usually a
Diagnosed with Asthma and Type 2 Diabetes. muffin or pumpkin bread, lunch is a sandwich, dinner
Patient denies a diagnosis of high blood pressure, is a homemade meal of a meat and vegetable,
but states that it is on the high side. She does not snacks are French fries or pretzels. Over the past
check it regularly. month she has increased her consumption of diet
ER visit for foot wound 3 months ago soda and “energy” drinks due to her feelings of
Past history of hospitilizations for asthma. Last one tiredness. She generally drinks 2 energy drinks
was many years ago. before class to “keep her focused” but states that
Patient has no known history of heart disease or they also make her “jittery”. She denies use of
high cholesterol. tobacco, alcohol, and illicit drugs. She does not
exercise.
Social History: Patient notes a heightned stress level
lately due to work and school. She also has feelings Review of Systems: General: Denies changes in
of anxiety. Patient's diet seems to be average. weight, but complains of end of day fatigue. She
Patient consumes a high amount of caffeine denies fevers, chills, and night sweats. She
including diet soda and up to two energy drinks a complains of intermittent dizziness.
day. Patient does not exercise regulalry. Patient • Cardiac: Denies a diagnosis of hypertension, but
drinks occasionally with the last drink being two states that she has been told her blood pressure
weeks ago. Patient does not smoke. Patient does was high in the past. She checks it at CVS
not do drugs. periodically. At last check it was “140/80 or 90”. She
denies known history of murmurs, angina, previous
Family History: Family has history of Cornoray Artery palpitations, dyspnea on exertion, orthopnea,
Disease, high cholesterol, hypertension, stroke, and paroxysmal nocturnal dyspnea, or edema. She has
obesity. never had an EKG.
• Respiratory: She denies shortness of breath,
ROS: wheezing, cough, sputum, hemoptysis, pneumonia,
General: Patient denies any recent illnesses, denies bronchitis, emphysema, tuberculosis. She has a
fever, denies nausea, reports low energy. history of asthma, last hospitalization was age 16 for
asthma, last chest XR was age 16.
Cardio: Patient denies shortness of breath, chest • Hematologic: She denies history of anemia, easy
pain, edema, circulation problems, easy bleeding, bruising or bleeding, petechiae, purpura, or blood
and dizziness. transfusions.
https://www.coursehero.com/file/36351689/NR-509-Cardiovascular-Documentation-Shadowpdf/
https://chamberlain.shadowhealth.com/assignment_attempts/4221355 2/5
