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Week7

Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.

History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom:

1. Location

2. Quality

3. Quantity or severity

4. Timing, including onset, duration, and frequency

5. Setting in which it occurs

6. Factors that have aggravated or relieved the symptom

7. Associated manifestations

Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.

Allergies: Include specific reactions to medications, foods, insects, and environmental factors.

Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.

Past Surgical History (PSH): Include dates, indications, and types of operations.

Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.

Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.

Immunization History: Include last Tdp, Flu, pneumonia, etc.

Significant Family History: Include history of parents, Grandparents, siblings, and children.

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. You will only need to cover systems pertinent to your CC, HPI (N/A, UNKNOWN is not acceptable, make up the information if you need to). To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

Cardiovascular/Peripheral Vascular:

Respiratory:

Gastrointestinal:

Musculoskeletal:

Psychiatric:

OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.

Physical Exam:

Vital signs: Include vital signs, ht, wt, temperature, and BMI and pulse oximetry.

General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.

Cardiovascular/Peripheral Vascular: Always include the heart in your PE.

Respiratory: Always include this in your PE.

Gastrointestinal:

Musculoskeletal:

Neurological:

Skin:

Diagnostic Test/Labs: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses with rationale for each one documented OR ones that were mentioned during the SH assignment.

ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled.

© 2021 Walden University

2/15/2021 Cardiovascular | Completed | Shadow Health

https://app.shadowhealth.com/assignment_attempts/9117273 1/3

Cardiovascular Results | Turned In
Nursing 562/562L Advanced Health Assessment – Spring 2021, N562

Return to Assignment (/assignments/433794/)

Documentation / Electronic Health Record

Document: Provider Notes

Student Documentation Model

Documentation

Your Results Reopen (/assignment_attempts/9117273/reopen)
Lab Pass (/assignment_attempts/9117273/lab_pass.pd

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation
Document: Provider Notes

Support

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Student Documentation Model Documentation

Subjective

Mr Jomes ios a 28-year old african american femal presentign with
3-4 eposodes of her heart, “beatign too fast” for 5 to 10 minutes per
episode over the last month. She describes the palpitations as a
“thumping” in her chest, that makes her feel anxious and
uncomfortable. The episodes anre not associated with a specific
activity, but has noticed it occurs on her way to class in the
mnorning. She denies any chest pain and states the palpitations
resolve when she calms down and breathes.She states this is the
first time she has had any heart trouble, and denies any previous
cardiac testing or surgeries. Pt states she is allergic to cats and dust,
which can trigger her asthma. She is compliant with her asthma
dmedications and has not experienced a recent attack. Patient is
allergic to penicillin, denies allergy to latex or foods. Pt takes flovent
and proventil for her asthma and denies other medications of
suppliments. Diagnosed with diabetes a few years ago. She states
she has been stressed lately with work at a copy center as a
suprvisor and school. She reports a typical diet and consumes about
4 diet cokes and and energy drink or two in the morning.

She attributess feeling tired to school and work. She is comfortanle
with her current weight, and reports no weight changes. denise fever,
chills, dizzyness, reports known hypertension not controlled by
medication, no murmurs , experiences ocassional dyspnea on
exertion climbing stairs or when hurrying. She reports one recent
hospitalization for a foot injury.

Ms. Jones is a pleasant 28-year-old African American woman wh
presented to the clinic with complaints of 3-4 episodes of rapid h
rate over the last month. She is a good historian. She describes
these episodes as “thumping in her chest” with a heart rate that
“way faster than usual”. She does not associate the rapid heart r
with a specific event, but notes that they usually occur about onc
per week in the morning on her commute to class. The episodes
generally last between 5 and 10 minutes and resolve spontaneou
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 associa
anxiety regarding her rapid heart rate. She denies shortness of
breath. She denies any association of symptoms with exertion. S
has no known cardiac history and has never had episodes prior t
this last month. She has not attempted any treatment at home an
states that she is only coming to the clinic today because her fam
has expressed concern regarding these episodes.

Social History: Ms. Jones has a job at a copy and shipping store
is a student at Shadowville Community College. She states that
has been feeling more “stressed” lately due to her school and wo
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 b
drinking as much water as her normal. Breakfast is usually a muffi
or pumpkin bread, lunch is a sandwich, dinner is a homemade m
of a meat and vegetable, snacks are French fries or pretzels. Ove
the past month she has increased her consumption of diet soda
“energy” drinks due to her feelings of tiredness. She generally dr
2 energy drinks before class to “keep her focused” but states tha
they also make her “jittery”. She denies use of tobacco, alcohol,
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 ni
sweats. She complains of intermittent dizziness.
• Cardiac: Denies a diagnosis of hypertension, but states that sh
has been told her blood pressure was high in the past. She chec
at CVS periodically. At last check it was “140/80 or 90”. She den
known history of murmurs, angina, previous palpitations, dyspne
exertion, orthopnea, paroxysmal nocturnal dyspnea, or edema. S
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 wa
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.

Objective

Ms hjones appears in no acute distress, able to speak in =ull
sentences with a wide appropriate variety of vocabulary and is
cooperative. She maintaines appropriate eye contact throught the
exam and sits with good posture, no ticks or twitches.

CV: PMI is brisk and tapping, 2 cm diameter, HR RRR s1 s2 present,
no murmurs rubs gallops clicks. All pulses +2 bilaterally without
bruits or thrills. No JVD capilary refil <3 sec in all extremities. No peripherial edema. EKG NSR without St elevation or depression or other significant findings. Resp: Chest symmetrical, breathign at ease, regular depth, rise and fall noted. No acessory muscle use or other signs of distress. Breath sounds clear in all fields without advantisious sounds.

• General: Ms. Jones is a pleasant, obese 28-year-old African
American woman in no acute distress. She is alert and oriented.
maintains eye contact throughout interview and examination.

• Cardiovascular: PMI is non-displaced, brisk and tapping, diame
2 cm. Regular rate and rhythm, S1 and S2 present, no murmurs,
rubs, gallops, clinics, precordial movements. Pulses 2+ and equa
bilaterally in upper extremities and lower extremities without thril
No temporal, carotid, abdominal aorta, femoral, iliac, or renal bru
No JVD. Capillary refill < 3 seconds. No peripheral edema. EKG w regular sinus rhythm, no ST changes. ABI is 0.97. • Respiratory: Chest is symmetrical with respirations; no physica abnormalities present on chest wall. Lung sounds clear to auscultation without wheezes, crackles, or cough.

Assessment

Palpitations seem related to caffeine use and or anxiety and stress.
Palpitations related to caffeine and/or anxiety

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Student Documentation Model Documentation

Plan

Encourage Ms Jones to reduce caffeine use and monitor her signs
and symptoms keeping a log.
Obtain EKG to rule out abnormalaites
Provide education on decreased caffeine consumpton
Monitor stress and anxiety levels and consiter mental health referral
as needed
Provide hypertension and diet education
Provide education on what to do if Ms Jones experiences
unresolvoing palpitations and or chest pain – call 911 procede to ER.
Schedule follow up visit in 4 weeks.

Encourage Ms. Jones to continue to monitor symptoms and log
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 inta
of water and other fluids.
• Educate on anxiety reduction strategies including deep breathin
relaxation, and guided imagery. Continue to monitor and explore
need for possible referral to social work/psychiatry or pharmacol
intervention.
• Discuss the need to maintain a stable blood pressure. Encoura
Ms. Jones to continue to monitor her blood pressure when a cuff
machine is available.
• Educate Ms. Jones on when to seek emergent care including
episodes of chest pain unrelieved by rest, palpitations that do no
dissipate after anxiety related strategies were implemented, chan
in vision, loss of consciousness, and sense of impending doom.
• Revisit clinic in 2-4 weeks for follow up and evaluation.

Comments

If your instructor provides individual feedback on this assignment, it will appear here.

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04 Cardiovascular-Tina Abnormals Graduate Fall 2015

 Health Assessment (Walden University)

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Page 1 of 3

Cardiovascular – TINA JONES™
ADVANCED HEALTH ASSESSMENT

In
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Over the last month, Tina has experienced 3 -4 episodes of perceived rapid heart rate. 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 specifi c 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 denies chest pain during the

episodes.

Timeframe: 4 months after establishing primary care (Age: 28)
Reason for visit: Patient presents complaining of recent episodes of fast heartbeat.

Module 4 – Cardiovascular

Develop strong communication skills
� Interview the patient to elicit subjective health information about her health and health history

� Ask relevant follow-up questions to evaluate patient condition
� Demonstrate empathy for patient perspectives, feelings, and sociocultural background
� Identify opportunities to educate the patient

Document accurately and appropriately
� Document subjective data using professional terminology

� Organize appropriate documentation in the EHR

Demonstrate clinical reasoning skills
� Organize all components of an interview

� Assess risk for disease, infection, injury, and complications

After completing the assessment, you will refl ect on personal strengths, limitations, beliefs, prejudices, and values.

Learning Objectives

I’ve noticed my heart has been beating faster than
usual lately, and I thought it was something I should
get checked out.“

R00.2, Palpitations

Underlying ICD- 10 Diagnoses

� Student Performance Index – This style of rubric contains subjective and objective data categories. Subjective

data categories include interview questions and patient data. Objective data categories include examination
and patient data.

Module Features

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Cardiovascular – TINA JONES™
ADVANCED HEALTH ASSESSMENT
In
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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
specifi c 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.

History of Present Illness

Medications

1. Fluticasone propionate, 110 mcg 2 puff s BID (last
use: this morning)

2. Albuterol 90 mcg/spray MDI 2 puff s Q4H prn (last

use: “a month ago”)
3. Acetaminophen 500- 1000 mg PO prn (headaches)
4. Ibuprofen 600 mg PO TID prn (cramps)

Vitals

� Weight (kg) – 87
� BMI – 30.1
� Heart Rate (HR) – 90
� Respiratory Rate (RR) – 16

� Pulse Oximetry – 99%
� Blood Pressure (BP) – 145/90
� Blood Glucose – 140
� Temperature (F) – 98.9

� 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 a history of anemia, easy bruising or bleeding, petechiae, purpura, or blood transfusions.

Review of Systems

Printable “Answer Key” available within the Shadow Health DCE.

Subjective and Objective Model Documentation

� Symptoms – Fast heartbeat
� Diagnosis – Palpitations

Chief Complaint

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Cardiovascular – TINA JONES™
ADVANCED HEALTH ASSESSMENT
In
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Abnormal Findings

Subjective (Reported by Tina)
� Experienced 3-4 episodes of fast heartbeat and a

“thumping feeling” in the last month
� Episodes accompanied by mild anxiety
� Increased stress related to work and school
� Increased caff eine consumption from diet soda and

energy drinks
� Risk factors for cardiovascular disease: type 2

diabetes, sedentary lifestyle and family history of
high cholesterol and hypertension

Objective (Found by the student performing physical exam)
� Heart rate in the clinic is not tachycardic: 90 bpm
� Hypertensive blood pressure reading: 145 / 90
� Risk factor for cardiovascular disease: Obesity (BSM

31)

Assessment

Palpitations related to caff eine and/or anxiety

Plan

1. Encourage Ms. Jones to continue to monitor symptoms and log her episodes of palpitations with associated
factors and bring log to next visit.

2. Obtain EKG to rule out any cardiac abnormality and assess for symptom correlated EKG changes. If
inconclusive, consider ambulatory EKG monitoring and referral to Cardiologist

3. Encourage to decrease caff eine consumption and increase intake of water and other fl uids.
4. 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.
5. 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.
6. 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.

7. Revisit clinic in 2 4 weeks for follow up and evaluation.

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Assessment of the Heart, Lungs, and Peripheral Vascular System

This week, you will evaluate abnormal findings in the Chest and Lungs. In addition, you will appraise health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system.

Assignment 1: Digital Clinical Experience: In this DCE Assignment, you will conduct a focused exam related to chest pain using the simulation tool, Shadow Health. Consider how a patient’s initial symptoms can result in very different diagnoses when further assessment is conducted.

In a Focus note, include General Assessment, Heart, Lungs and Affected System. Use Scholarly references, Peer-reviewed articles, Research Articles, Professional Organization Recommendations and Walden’s Library or your current textbook. When documenting your Focus note, refer to SOAP note Template, this will ensure you include all required information. Review Rubric before submission.

Subjective Documentation in Provider Notes

Subjective narrative documentation in Provider Notes is detailed and organized and includes:

Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)

ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows:

General: Head: EENT: etc.

Objective Documentation in Provider Notes –

Physical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”.

You only need to examine the systems that are pertinent to the CC, HPI, and History.

Diagnostic result – Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned

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