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
History of Presenting Ill
...
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
History 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.
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7/4/2021 Cardiovascular | Completed | Shadow Health
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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 (
[email protected])
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
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