NR 509 Cardiovascular | Completed documentation
NR 509 Cardiovascular | Completed documentation Cardiovascular Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment Your Results Lab Pass Documentation / Electronic Health Record Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation Subjective Tina Jones a 28 year old of female African American descent. 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
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