5/24/2018 Cardiovascular | Completed | Shadow Health
NR 509 Cardiovascular | Completed documentation
Cardiovascular Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-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
Subjective month
Review Questions Tina Jones a 28 year old of female African American
descent.
Self-Reflection CC:
Ms. Jones States " I've been noticing my heart
seems to be beating too fast every once in awhile
lately, and it starts to worry me. My mom said I
should make an appointment. You do not want to
ignore heart stuff, I guess."
HPI: fast heart rate on occasion on said one month
ago. Denies any heart problems. Complains of heart
beat fast making patient uncomfortable and
anxious. Unsaid 1 month ago approximately once a
week for the past month. For a total of three to
four times. lasting 5 to 10 min max. In resolving on
their own. Usually when patient is on her way to
class reports recent use of energy drinks. Reports
the elevation in heart rate is when drinking energy
drinks. Patient reports a " thumping" making her
anxious and umcomfortable. heartbeat a 3 out of 10
denies any history of high blood pressure. Reports
palpitations in the morning, denies any physical
activity or eating exacerbates palpitations. patient
reports to believe it could be the caffeine in the
energy drinks. Denies taking any medication for
palpitations and reports deep breathing and trying
to relax helps relieve palpitations. Denies any
history of high blood pressure last time blood
pressure was checked when she was seen in the
clinic last 140/80. Educated patient on her blood
pressure today on keeping it on the low side and
documenting blood pressure also checking blood
pressure when cuff is available. Patient reports that
she believes her blood pressure is usually normal.
Denies any heart problems heart murmurs any
swelling to the upper and lower extremities.
Denies any shortness of breath. Denies any cardiac
history of her own. New prescription of flovent last
This study source was downloaded by 100000851646087 from CourseHero.com on 01-16-2023 05:47:20 GMT -06:00
https://chamberlain.shadowhealth.com/assignment_attempts/3526057 1/4
https://www.coursehero.com/file/31240643/Cardiovascular-Completed-documentation-pdf/
, 5/24/2018 Cardiovascular | Completed | Shadow Health
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
This study source was downloaded by 100000851646087 from CourseHero.com on 01-16-2023 05:47:20 GMT -06:00
https://chamberlain.shadowhealth.com/assignment_attempts/3526057 2/4
https://www.coursehero.com/file/31240643/Cardiovascular-Completed-documentation-pdf/
NR 509 Cardiovascular | Completed documentation
Cardiovascular Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-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
Subjective month
Review Questions Tina Jones a 28 year old of female African American
descent.
Self-Reflection CC:
Ms. Jones States " I've been noticing my heart
seems to be beating too fast every once in awhile
lately, and it starts to worry me. My mom said I
should make an appointment. You do not want to
ignore heart stuff, I guess."
HPI: fast heart rate on occasion on said one month
ago. Denies any heart problems. Complains of heart
beat fast making patient uncomfortable and
anxious. Unsaid 1 month ago approximately once a
week for the past month. For a total of three to
four times. lasting 5 to 10 min max. In resolving on
their own. Usually when patient is on her way to
class reports recent use of energy drinks. Reports
the elevation in heart rate is when drinking energy
drinks. Patient reports a " thumping" making her
anxious and umcomfortable. heartbeat a 3 out of 10
denies any history of high blood pressure. Reports
palpitations in the morning, denies any physical
activity or eating exacerbates palpitations. patient
reports to believe it could be the caffeine in the
energy drinks. Denies taking any medication for
palpitations and reports deep breathing and trying
to relax helps relieve palpitations. Denies any
history of high blood pressure last time blood
pressure was checked when she was seen in the
clinic last 140/80. Educated patient on her blood
pressure today on keeping it on the low side and
documenting blood pressure also checking blood
pressure when cuff is available. Patient reports that
she believes her blood pressure is usually normal.
Denies any heart problems heart murmurs any
swelling to the upper and lower extremities.
Denies any shortness of breath. Denies any cardiac
history of her own. New prescription of flovent last
This study source was downloaded by 100000851646087 from CourseHero.com on 01-16-2023 05:47:20 GMT -06:00
https://chamberlain.shadowhealth.com/assignment_attempts/3526057 1/4
https://www.coursehero.com/file/31240643/Cardiovascular-Completed-documentation-pdf/
, 5/24/2018 Cardiovascular | Completed | Shadow Health
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
This study source was downloaded by 100000851646087 from CourseHero.com on 01-16-2023 05:47:20 GMT -06:00
https://chamberlain.shadowhealth.com/assignment_attempts/3526057 2/4
https://www.coursehero.com/file/31240643/Cardiovascular-Completed-documentation-pdf/
