DPatel_Cardiovascular_12082020.docx - 1 Documentation of an...

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1 Documentation of an Assessment of the Cardiovascular System 6 th December 2020 REGIONAL WRITE UP- Cardiovascular System Date- December 6 th , 2020 Examiner- Divya, RN Patient- XYZ Age- 47yrs Gender- Female
2 Reason for Visit- Physical Examination Health history 1. Does the patient have shortness of breath, chest pain or tight chest? No. 2. Does the patient use more than one pillow to sleep? No. 3. Does the patient have cough? No. 4. Does the patient seem to get tired easily? No. 5. Does the patient experience any change in coloration of skin, blue or ash coloration? No. 6. Does the patient have swelling in the legs or feet? No. 7. Does the patient have to wake up at night to urinate? Yes. 8. Does the patient have any history of heart disease or a family history of heart disease? No. 9. Is the patient experiencing any changes in the daily activities? No. 10. Current medication? None. 11. Does the patient smoke or drink alcohol? No. 12. Number or cigarettes or drinks per day? NA.

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