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 any shortness of breath. Denies any cardiac history of her own. New prescription of flovent last month 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