Cabrillo CollegeNUR MISCShadow Health Focused Exam- Anxiety John Larsen

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Shadow Health Anxiety John Larsen ED Nursing Note Student Response Model Documentation Chief Complaint (No Documentation Made) Mr. Larsen is a 48-year-old White man who presented to the ED a... t 6 AM with a perceived cardiac complaint; he reports being exhausted, scared and unable to relax from last night. History of Present Illness (No Documentation Made) Hx of HTN, hyperlipidemia, and osteoarthritis, presented in the ED this morning with complaints of exhaustion, anxiety, terror, and tachycardia which started last night 3 AM. Patient reports that the worry has been around since he was diagnosed with HTN (a year ago), but becomes worse last night. He states that he feels like he is choking, his body is sweating, shivering and he has been unable to control his fear since 3 AM. He says that he is scared about everything, especially his hypertension; he tried to take a deep breath several times to feel calm but did not work. He states that he came to the ED because he thought he was having a heart attack from his hypertension. He says that the anxiety causes him to skip work, prevents social interaction and that it affects his concentration and sleeping patterns. He denies any chest pain, fever, mood changes, or suicidal thoughts. Allergies (No Documentation Made) Codeine Past Medical History (No Documentation Made) HTN since age 47 Osteoarthritis since age 46 Hyperlipidemia since age 45 Past Surgical History (No Documentation Made) Total knee replacement age 48 Medication History (No Documentation Made) Atorvastatin 20 mg P.O. daily for high cholesterol. Last dose: yesterday Lisinopril 10 mg P.O. daily for hypertension. Last dose: yesterday Fish oil 1 tab daily for high cholesterol. Last dose: yesterday Family History (No Documentation Made) Mother, living, high cholesterol Father died of lung cancer, had HTN, deceased age 50 No known family history of mental illness [Show More]

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