NURS 6315Cardiovascular _ Completed _ Shadow Health Completed A

6/25/2018 Cardiovascular | Completed | Shadow Health Cardiovascular Results | Completed Advanced Health Assessment - Summer 2018, NURS 6315 Return to Assignment Your Results T Turn In urn In Reopen Reopen Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Documentation / Electronic Health Record Lab Pass Lab Pass This study resource was shared via CourseH6/25/2018 Cardiovascular | Completed | Shadow Health Student Documentation Model Documentation Subjective 28 year old, African American female presents to the clinic with complaints of recent episodes of a fast heartbeat. States "it has been occasionally beating really fast in the last few weeks. It only lasts a few minutes, and it feels normal the rest of the time". Reports that school has become really busy and recently started drinking energy drinks 1-2 in the mornings. Also consumes 4 diet cokes per day, denies coffee. Reports feeling anxious and uncomfortable during episode. PMH: asthma and diabetes Family Hx: father, died at 58 of a MI Social Hx: single, no children. No daily exercise greater than baseline. Drinks energy drinks and diet cokes throughout the day. Denies smoing or illicit drug use. ROS: adequate diet 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 before class to “keep her focused” but states that they also make her “jittery”. She denies use of tobacco, alcohol, and illicit drugs. She does not exercise. Review of Systems: General: Denies changes in weight, but complains of end of day fatigue. She denies fevers, chills, and night sweats. She complains of intermittent dizziness. • Cardiac: Denies a diagnosis of hypertension, but states that she has been told her blood pressure was high in the past. She checks it at CVS periodically. At last check it was “140/80 or 90”. She denies known history of murmurs, angina, previous palpitations, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or edema. She has never had an EKG. • Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16 for asthma, last chest XR was age 16. • Hematologic: She denies history of anemia, easy bruising or bleeding, petechiae, purpura, or blood transfusions. This study resource was shared via CourseH6/25/2018 Cardiovascular | Completed | Shadow Health Student Documentation Model Documentation Objective Vital Signs upon arrival to clinic: 145/90; HR 90; R 16; T 98.9; SpO2 99% RA. The patient is friendly and well groomed. She is not in any obvious distress. Chest: symmetric, without visible abnormal findings. Respiratory: lungs clear on auscultation. Breath sounds present in all lung fields. No adventitous sounds. Cardiac: regular rate and rhythm. S1 and S2 audible. No murmurs, gallops, or extra sounds; JVD less than 4cm at the sternal angle. Temoral and Carotid arteries without thrill or bruit, 2+. PMI present at midclavicular line with 5th intercostal space, brisk and tapping, less than 3 cm. Radial, bracial, popliteal, tibial, and dorsalis pedis arteries without thrill and 2+ bilaterally. Iliac and femorial arteries without bruit bilaterally Abdomen: abdominal aorta without bruit bilaterally Renal: renal arteries without bruit bilaterally Extremities: 2+ radial and dorsalis pulses no clubbing or cyanosis or edema. Capillary refill bilateral at upper and lower extremities less than 3 seconds. Tests: ABI 0.9-1.0 mildly ischemic EKG: Sinus rhythm, no ST changes. • General: Ms. Jones is a pleasant, obese 28-yearold African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination. • Cardiovascular: PMI is non-displaced, brisk and tapping, diameter 2 cm. Regular rate and rhythm, S1 and S2 present, no murmurs, rubs, gallops, clinics, precordial movements. Pulses 2+ and equal bilaterally in upper extremities and lower extremities without thrills. No temporal, carotid, abdominal aorta, femoral, iliac, or renal bruits. No JVD. Capillary refill < 3 seconds. No peripheral edema. EKG with regular sinus rhythm, no ST changes. ABI is 0.97. • Respiratory: Chest is symmetrical with respirations; no physical abnormalities present on chest wall. Lung sounds clear to auscultation without wheezes, crackles, or cough. Assessment 1. Fast Heart beat - presentation suggestive of cardiac palpitations due to recent use of energy drinks Palpitations related to caffeine and/or anxiety Plan ABIs; EKG; education on effects of caffiene in energy drinks and increase in heart rate. Alternative coping strategies for stress. Encourage Ms. Jones to continue to monitor symptoms and log her episodes of palpitations with associated factors and bring log to next visit. • Obtain EKG to rule out any cardiac abnormality and assess for symptom-correlated EKG changes. If inconclusive, consider ambulatory EKG monitoring and referral to cardiology. • Encourage to decrease caffeine consumption and increase intake of water and other fluids. • Educate on anxiety reduction strategies including deep breathing, relaxation, and guided imagery. Continue to monitor and explore the need for possible referral to social work/psychiatry or pharmacologic intervention. • Discuss the need to maintain a stable blood pressure. Encourage Ms. Jones to continue to monitor her blood pressure when a cuff or machine is available. • Educate Ms. Jones on when to seek emergent care including episodes of chest pain unrelieved by rest, palpitations that do not dissipate after anxiety related strategies were implemented, changes in vision, loss of consciousness, and sense of impending doom. • Revisit clinic in 2-4 weeks for follow up and evaluation. 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