CV doc.pdf - Cardiovascular | Completed | Shadow Health Cardiovascular Results | Completed Advanced Health Assessment September'17 NREO81 NRE-662 01A

CV doc.pdf - Cardiovascular | Completed | Shadow Health...

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10/17/2017 Cardiovascular | Completed | Shadow Health 1/4 Cardiovascular Results | Completed Advanced Health Assessment - September '17 , NREO81 NRE-662 01A Return to Assignment Your Results Turn In Lab Pass Document: Provider Notes Document: 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
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10/17/2017 Cardiovascular | Completed | Shadow Health 2/4 Student Documentation Model Documentation Subjective Tina Jones is a 28 year old African American woman who presented to the clinic with complaints of heart palpitations that began one month ago. She states that she feels anxious when they happen. She states that she has been drinking energy drinks to cope with mounting coursework, and she generally notices the fast heartbeat when she's on her way to class in the mornings. She states that she has 1-2 energy drinks in the mornings. She also states that she drinks 4 diet cokes a day, as well. She has not checked her heart rate during these episodes. Treatment wise she tries to slow her breathing and relax. States she has no history of heart problems, but has a history of occassional high readings of blood pressures. The patient does not check blood pressures, it is only checked when seen at medical visits. Patient denies VTE, DVT, high cholesterol, and being diagnosed with hypertension or other heart issues. Family: history of HTN in parents and grandparents, same with high cholesterol, maternal grandma died of a stroke, mother's father died of a MI, negative for murmurs. Brother and father are/were "big" but not obese (brother possibly weighs 280 lbs at 6ft, father died in car accident).
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  • Summer '17
  • Dr. Iris Malone
  • Cardiology, heart rate, Ms. Jones

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