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 wit
...
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
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