Cardiovascular Results completed shadow health

Document Content and Description Below

Cardiovascular Results | Turned In Advanced Physical Assessment - May 2021, NUR 634 Return to Assignment (/assignments/493256/) Subjective Data Collection: 19 of 19 (100.0%) Chief Complaint Histo... ry of Presenting Illness Your Results Reopen (/assignment_attempts/10113755/reopen Lab Pass (/assignment_attempts/10113755/lab_pass.p Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Student Survey Indicates an item that you found. Indicates an item that is available to be found. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of t patient's case. Established chief complaint Reports recent episodes of palpitations Describes heart rate during episodes as feeling "faster than usual" Asked about onset Reports first episode a month ago Asked about frequency and duration of fast heartbeat episodes Reports episodes occur "about once a week" Reports 3-4 episodes total Reports fast heartbeat episodes last 5-10 minutes Asked about character of palpitations Describes palpitations as "thumping" or "pounding" Reports episodes accompanied by mild anxiety Asked about aggravating factors Reports that palpitations seem to occur more often in the morning Reports episodes not exacerbated by exertion Reports that episodes do not occur after eating Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Support Downloaded by Denis Munene (munenedenis957@gmail.com) lOMoARcPSD|16310140 7/4/2021 Cardiovascular | Completed | Shadow Health https://app.shadowhealth.com/assignment_attempts/10113755 2/3 Medical History Social Determinants of Health Social History Reports caffeine as a possible aggravating factor Asked about relieving factors Reports deep breathing and trying to relax Denies medication or other treatment Confirmed use of medications Confirms medications from previous visit Reports new inhaler Followed up on new inhaler New inhaler is Flovent Prescribed dose is two puffs Inhaler is prescribed for daily use Describes new inhaler regiment as effective Confirmed allergies Confirms allergies (no new allergies reported) Asked about personal history of hypertension Reports usual blood pressure "might be on the high side" Denies past diagnosis of hypertension Does not check BP regularly Is aware of risk factors for hypertension Asked about possible contributing factors in health history Reports no known history of heart disease Reports type 2 diabetes Reports no past diagnosis of high cholesterol Reports no history of rheumatic fever Reports no history of heart murmur Reports no EKG or other diagnostic cardiac tests Asked about stress and anxiety Reports occasional feelings of anxiety Reports recent increase in stress Reports stress related to school and work Asked about typical diet Breakfast is usually a muffin or pumpkin bread Lunch is usually a sandwich Dinner is usually a home-cooked meat dish and side of vegetables Snacks are pretzels or French fries Asked about caffeine consumption Reports increased caffeine consumption Reports consuming diet soda or energy drinks Reports caffeine increase was over last month Typical drinks 2 energy drinks before class Reports caffeine "keeps me focused but sometimes makes me jittery" Asked about exercise and activity level Reports general low activity level Downloaded by Denis Munene (munenedenis957@gmail.com) lOMoARcPSD|16310140 7/4/2021 Cardiovascular | Completed | Shadow Health https://app.shadowhealth.com/assignment_attempts/10113755 3/3 Review of Systems Family History Asked about substance use Reports occasional consumption of alcohol Last alcoholic drink was two weeks ago Denies history of tobacco use, including cigarettes Denies drug use Asked about general symptoms Denies recent respiratory or other illness Denies fever Denies nausea or vomitting Denies chills Reports low energy level Denies night sweats Asked about review of systems for cardiovascular Denies shortness of breath Denies chest pain or tightness Denies edema Denies circulation problems Denies easy bleeding or bruising Denies dizziness, lightheadedness, or syncope Asked about relevant family history Reports family history of heart disease or CAD Reports family history of high cholesterol Reports family history of hypertension Reports family history of myocardial infarction Reports family history of stroke Reports family history of obesity Comments If your instructor provides individual feedback on this assignment, it will appear here. © Shadow Health 2012 - 2021 (800) 860-3241 | Help Desk (https://support.shadowhealth.com/) | Terms of Service (/static/terms_of_service) | Privacy Policy ↗ (/static/privacy_policy) | Patents (https://www.shadowhealth.com/patents) ® Downloaded by Denis Munene (munened [Show More]

Last updated: 2 years ago

Preview 1 out of 4 pages