cardio model note.docx - Chief complaint rapid heart rate History of present illness Onset began one month ago Location midsternal to left-sided chest

cardio model note.docx - Chief complaint rapid heart rate...

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Chief complaint rapid heart rate History of present illness Onset began one month ago Location midsternal to left-sided chest Duration is 5 to 10 minutes Characteristics including something in her chest which makes her feel anxious Aggravating factors none reported Relieving factors include rest and deep breathing Treatment none reported current medications Flovent daily two Puffs twice day Proventil two Puffs as needed for shortness of breath Tylenol 500 mg tabs po Q4 hours PRN for headaches Ibuprofen 200 mg 3 tablets q6 hours PRN for menstrual cramps Allergies Cats induce sneezing itchy eyes and difficulty breathing Dust induces sneezing difficulty breathing and itchy eyes Penicillin causes hives Past medical history Asthma diagnosed at 2.5 years old Diabetes diagnosed at 24 years old Denies surgical history Last tetanus booster was one year ago States immunizations are up-to-date Social history Patient is a supervisor at Mid-American ship and copy she is attending school to obtain her bachelor's degree in accounting Patient states she has been under a bigger amount of stress lately between work and school. Patient denies tobacco use Patient states she drinks up to 3 drinks of liquor when she goes out in Social gatherings. Patient states are smoke detectors are currently functioning at home Patient states she has been eating 3 meals daily. Patient states she drinks approximately two energy drinks in the morning every day before school. She has started drinking energy drinks for the past month. Patient denies regular exercise States she is on her feet most of the day 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.
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  • Fall '15
  • pulse, Ms. Jones, hypercholesterolemia

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