lOMoAR cPSD| 57629747
Cardiovascular Results shadow health
, lOMoAR cPSD| 57629747
Document: Provider Notes
Student Documentation Model Documentation
Subjective Ms. Jones is a pleasant 28-year-old African American
Tina Jones is a calm and cooperative 28 yo african woman who presented to the clinic with complaints of 3-4
american woman presenting to the clinic with complains of episodes of rapid heart rate over the last month. She is a
3-4 episode of a racing heart over the past month. She is good historian. She describes these episodes as “thumping
alert and oriented. States the racing heart as "thumping in in her chest” with a heart rate that is “way faster than
her chest, making me feel anxious and uncomfortable." usual”. She does not associate the rapid heart rate with a
she reports a heart rate faster than usuall, as if she ran up specific event, but notes that they usually occur about once
a flight of stairs. There is no particular triggers but does per week in the morning on her commute to class. The
notice they happen in the morning on her commute to episodes generally last between 5 and 10 minutes and
school. The episodes last 5-10 minutes and resolve without resolve spontaneously. She does not know her normal
intervention. She does not know her normal bloodpressre heart rate or her heart rate during these episodes. She
or heart rate. she denies shortness of breath or chest pain, denies chest pain during the episodes, but does endorse
or difficulty breathing with exertion. she has no cardiac discomfort of 3/10 which she attributes to associated
history and has not had symptoms like this before. she has anxiety regarding her rapid heart rate. She denies
not attempted to treat herself but does find they make her shortness of breath. She denies any association of
anxious. She only came in due to her mother being symptoms with exertion. She has no known cardiac history
concerned. She woks 32hrs a week as a supervisor at a and has never had episodes prior to this last month. She
copy and shipping store and is a student in college taking 2 has not attempted any treatment at home and states that
classes at shadowville state college. She has been feeling she is only coming to the clinic today because her family
more tired at the end of the day. denies changes in diet has expressed concern regarding these episodes. Social
and her usual diet consists of pumpin bread for breakfast, History: Ms. Jones has a job at a copy and shipping store
sandwich for lunch, and homemade meals with protein and and is a student at Shadowville Community College. She
a vegetable, and has occational snacks of fries. she tries to states that she has been feeling more “stressed” lately due
stay away from sweets. shes increased her soda and to her school and work. She has been feeling tired at the
energy drinks due to being tired, requiring 2 energy drinks 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 and 4 sodas daily. shes needed to increase her energy consumption of
diet soda and “energy” drinks due to her drinks before class but they make her jittery. she denies feelings of tiredness. She
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Cardiovascular Results shadow health
, lOMoAR cPSD| 57629747
Document: Provider Notes
Student Documentation Model Documentation
Subjective Ms. Jones is a pleasant 28-year-old African American
Tina Jones is a calm and cooperative 28 yo african woman who presented to the clinic with complaints of 3-4
american woman presenting to the clinic with complains of episodes of rapid heart rate over the last month. She is a
3-4 episode of a racing heart over the past month. She is good historian. She describes these episodes as “thumping
alert and oriented. States the racing heart as "thumping in in her chest” with a heart rate that is “way faster than
her chest, making me feel anxious and uncomfortable." usual”. She does not associate the rapid heart rate with a
she reports a heart rate faster than usuall, as if she ran up specific event, but notes that they usually occur about once
a flight of stairs. There is no particular triggers but does per week in the morning on her commute to class. The
notice they happen in the morning on her commute to episodes generally last between 5 and 10 minutes and
school. The episodes last 5-10 minutes and resolve without resolve spontaneously. She does not know her normal
intervention. She does not know her normal bloodpressre heart rate or her heart rate during these episodes. She
or heart rate. she denies shortness of breath or chest pain, denies chest pain during the episodes, but does endorse
or difficulty breathing with exertion. she has no cardiac discomfort of 3/10 which she attributes to associated
history and has not had symptoms like this before. she has anxiety regarding her rapid heart rate. She denies
not attempted to treat herself but does find they make her shortness of breath. She denies any association of
anxious. She only came in due to her mother being symptoms with exertion. She has no known cardiac history
concerned. She woks 32hrs a week as a supervisor at a and has never had episodes prior to this last month. She
copy and shipping store and is a student in college taking 2 has not attempted any treatment at home and states that
classes at shadowville state college. She has been feeling she is only coming to the clinic today because her family
more tired at the end of the day. denies changes in diet has expressed concern regarding these episodes. Social
and her usual diet consists of pumpin bread for breakfast, History: Ms. Jones has a job at a copy and shipping store
sandwich for lunch, and homemade meals with protein and and is a student at Shadowville Community College. She
a vegetable, and has occational snacks of fries. she tries to states that she has been feeling more “stressed” lately due
stay away from sweets. shes increased her soda and to her school and work. She has been feeling tired at the
energy drinks due to being tired, requiring 2 energy drinks 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 and 4 sodas daily. shes needed to increase her energy consumption of
diet soda and “energy” drinks due to her drinks before class but they make her jittery. she denies feelings of tiredness. She
messages.downloaded_by
