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NR 509 Cardiovascular Documentation Shadow

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Student Documentation Model Documentation Subjective TJ, 28 years, Female, African American CC: Heart palpitations, "heart beating too fast" HPI: Tina, a 28 year old african american female, came... into the clinic with complaints of her "heart beating too fast" and "faster than usual." It started about a month ago when work and school started to become more stressful and busy. She has had 3 to 4 episodes total and the episodes last between 5 and 10 minutes. She described the palpitations as "pounding" or "thumping." She feels anxiety as the symptoms start to appear. She states that the symptoms are worse in the morning, but physical activity or eating do not make them worse. Patient has not attempted any form of treatment for the palpitations. Current medications: Fluticasone 110mcg per 2 puffs daily Albuterol 90mcg per puff, 2 puffs as needed Acetaminophen 500-1000mg as needed for headaches Ibuprofen 600mg as needed for menstrual cramps Allergies: Environmental: Cats, Dust Medication: Penicillen No new allergies since last visit. Medical History: Diagnosed with Asthma and Type 2 Diabetes. Patient denies a diagnosis of high blood pressure, but states that it is on the high side. She does not check it regularly. ER visit for foot wound 3 months ago Past history of hospitilizations for asthma. Last one was many years ago. Patient has no known history of heart disease or high cholesterol. Social History: Patient notes a heightned stress level lately due to work and [Show More]

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