Patient Summary & Nursing Note: A-Fib, Depressive Disorder
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Concordia University Portland *
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382
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Electrical Engineering
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Jun 12, 2024
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docx
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@ Home - CSPComnect X Il View Assessment B | Course Actvites - EHR Tutor - student.atitesting.com/LTI x |+ wlation: EHR Tutor atl Module: Course Activities EHR Tutor Concordia U MN BSN Patient Summary Patient Information Show 10 & entries Results v Note Time + Note Type Provider v © 12/16/2023 1652 Nursing Note Allergies & Home Medications Immunization Record Notes Flowsheets o Showing 1 to 1 of 1 entries Screenings v —IXk search: Professional Role Created By Nurse Lisa DeFrates Edit Note Ptis a 65 yo female that is ARO x4 with Dx of persistent A-Fib, major depressive disorder and Atherosclerotic heart disease. Pt has allergies to ciprofloxacin, ‘gabapentin, & sulfa antibiotics. Prior to admission pt was in a car accident with multiple fractures and reportedly lost her job and her home since. Today pt appears to be generally in a good mood and denies having any pain. Pt's lungs were clear to auscultation in all lobes with no adventurous sounds noted. Cardiac assessment also completed with no abnormal heart sounds noted. Abdominal assessment preformed and found to be somewhat rounded, nom-tender, non- distended, and normoactive bowel sounds present in all four quadrants. Vital signs: bp 128/74, P- 78, R- 18, T- 98.4, sp02- 97% on room air. 505 PM S 12/16/2023
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