NURS 6512 Assignment 1 Week 7: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System

NURS 6512 Assignment 1 Week 7: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System

NURS 6512 Assignment 1 Week 7 Digital Clinical Experience Assessing the Heart, Lungs, and Peripheral Vascular System

Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation

SUBJECTIVE DATA:

Chief Complaint (CC): ‘I have been experiencing troubling chest pains for the last one month.’

 

History of Present Illness (HPI): Brian Foster is a 58-year-old patient that came to the clinic with complains of experiencing troubling chest pains over the past one month. The patient reports that the chest pains last few minutes. Initially, he thought the chest pain was due to heartburns but have been worsening in nature. He describes the chest pain to be tight and unconformable located in the middle of the chest. Brian denies radiating, arm, crushing, or burning chest pain. He has experienced three episodes over the last month, which last for a few minutes. The patient currently reports no pain (0/10). The patient rated pain severity at its worst at 5/10 According to him, laying down with brief rest alleviate the chest pain. The onset of the chest pain was when he engaged in physical activity while doing yard work. The second episode was while taking stairs t work. His medications are current.

Medications: Brian is currently using the following medications:

Metoprolol 100 mg one po 1 day

Atorvastatin 20 mg po 1 day

Omega-3 fish oils 1200 mg on po q day last dose Thursday 8 am

Tylenol or Motrin when having a headache

Allergies: Brian reports that he is allergic to codeine, which causes nausea and vomiting when he uses it.

 

Past Medical History (PMH):the patient has hypertension and hyperlipidemia, which were diagnosed a year ago. He denies any history of surgeries.

 

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

The patient denes any history of surgeries.

Sexual/Reproductive History: Non contributory

 

Personal/Social History: Brian denies any history of illicit drug use or tobacco use. He drinks 2-3 alcoholic beverages per week. He only drinks during the weekends. He denies stress. He does not engage in regular exercises, with the last time being two years ago. His diet comprises granola bars, turkey subs and grilled meat and vegetables. He is unsure of his salt intake amount. He drinks four glasses of water a day. He drinks two cups of coffee a day. He does not frequently monitor his blood pressure at home.

Immunization History: His influenza vaccination record is up to date. TDAP was given last 10/2014.

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

Brian’s deceased father was hypertensive with hyperlipidemia, obesity and colon cancer. His mother has type 2 diabetes mellitus and hypertension at 80years. His sister aged 52 has type 2 diabetes mellitus and hypertension. His maternal grandfather died at 54 years due to heart attack while maternal grandmother died of cancer at the age of 65 years. His paternal grandmother died of pneumonia at 78 years while his daughter has asthma at the age of 19 years.

Review of Systems

General: the patient denies any fatigue, increased sweating, fever, chills, weight loss, or recent illness.

                Cardiovascular/Peripheral Vascular:He denies palpitations, angina, edema, circulation problems, blood clots, murmurs, or cyanosis,

                Respiratory: The patient denies sore throat, difficult in swallowing, cough, difficulty in breathing, shortness of breath, or shortness of breath.

Integumentary: The patient denies rashes, lesions or skin changes

OBJECTIVE DATA:

Physical Exam:

Vital signs:BP 146/88 mm Hg, MAP 109 mmhG, HR 104 bpm, RR 19, O2 saturation 98% room air, Temperature 36.7C (98F)

General: The patient is well groomed with no visible abnormal findings. He is alert, oriented, with clear speech and in no acute distress.

Cardiovascular/Peripheral Vascular: Jugular venous assessment shows its height of venous pressure to be less than 4 cm above the sternal angle. The chest is symmetrical with no visible abnormal findings. Presence of S1, S2, and S3 heart sounds on auscultation. There is also audible gallop. Absence of abdominal and lower extremity arteries bruit. Presence of a thrill and increased amplitude on palpating right carotid artery. The PMI is displaced laterally with brisk and tapping amplitude. Absence of thrill and abnormal amplitudes in brachial arteries. There are no thrills in popliteal, tibial, and dorsalis pedis arteries except diminished amplitudes. EKG reveals regular sinus rhythm with no ST elevation.

Respiratory: Patient breaths quietly, unlabored with clear breath sounds present in all the lung areas. Adventitious sounds heard to the lower posterior right and fine crackles and rales in the left posterior bases.

Gastrointestinal:The abdomen is symmetrical with no rash, distention, or bruising. Absence of bruits in abdominal aorta. Bowel sounds are normoactive. The abdomen is non-tender on palpation with not palpable mass or organomegaly. There is tympany on spleen, with liver span being 6-12 cm.

Neurological:Alert and oriented, follows commands, and moves all the extremities. 

Skin:capillary refill of less than 3 seconds, skin is warm, pink, dry, and intact without tenting, edema, and rashes.

Diagnostic Test/Labs:

Several diagnostic investigations are needed to develop an accurate diagnosis for the client. One of them is echocardiogram. An echocardiogram will provide accurate insight into the blood circulation through the heart valves and heart. An exercise stress test may also be essential for this patient. The test will enable the determination of cardiac functioning when the patient engages in his daily routines. A nuclear stress tests may also be needed. The nuclear stress tests will add the benefit of generating images of the ECG recordings while the patient engages in physical activity. A CT scan may also be prescribed. The test will enable the visualization of abnormalities such as the presence of calcification of the arteries. Lastly, cardiac catheterization may be done(Joshi & de Lemos, 2021). This will provide direct visualization of the blood vessels and presence of any blockages.

ASSESSMENT: Stable angina is the client’s primary diagnosis. Stable angina or angina pectoris is a cardiac condition that is characterized by inadequate cardiac tissue perfusion due to occlusion of blood flow. The occlusion impairs blood and oxygen supply to a specific region of the heart muscle, leading to tissue ischemia. Patients with stable angina experience symptoms such as chest pain, fatigue, dizziness, nausea, and shortness of breath when they engage in active physical activities that increase oxygen supply to the cardiac muscles(Ferraro et al., 2020; Joshi & de Lemos, 2021). Brian has symptoms that align with those seen in stable angina. He reports that the symptoms that include chest pain and fatigue develop when he engages in active physical activity. The symptoms also have the same duration and character whenever he experiences them, hence, the diagnosis of stable angina.

One of the differential diagnoses that should be considered in Brian’s case is myocardial infarction. Myocardial infarction occurs when there is complete or partial cessation of blood flow to the coronary artery. This causes damage to the heart muscle. Patients often experience symptoms such as chest pain, nausea, sweating, and chest pain referred to the neck or shoulders(Vogel et al., 2019; Zhang et al., 2022). These characteristics lack in Brian’s case study, hence, myocardial infarction is the least cause. The other differential diagnosis that should be considered in the case study is congestive heart failure. Congestive heart failure is a heart disorder that is characterized by the heart’s inability to pump blood throughout the body organs and tissues.  Patients can suffer from either right-sided or left-sided hear failure. Depending on the type, patients experience symptoms that include weight gain, chest pain, cough, edema, and jugular venous distention(Groenewegen et al., 2020; Palo & Barone, 2020; Slivnick& Lampert, 2019). Brian lacks these symptoms, making it the least likely cause of his health problem.

The other differential diagnosis that should be considered is aortic aneurysm. Aortic aneurysm is a disorder that develops following the weakening of the walls of the aorta. This causes budging and an increased risk of rupture if not treated on time. Patients experience symptoms such as sudden, sharp, crushing chest and back pain, rapid heart rate, and dizziness. The last differential diagnosis is pericarditis. Pericarditis refers to the inflammation of the pericardium due to causes such as infections. Patients experience symptoms such as chest pain and fever, which are not evidence in Brian’s case(Chiabrando et al., 2020). Therefore, additional diagnostic investigations should be undertaken to guide the diagnosis and treatment plan.

 

 

References

Chiabrando, J. G., Bonaventura, A., Vecchi,  é A., Wohlford, G. F., Mauro, A. G., Jordan, J. H., Grizzard, J. D., Montecucco, F., Berrocal, D. H., Brucato, A., Imazio, M., & Abbate, A. (2020). Management of Acute and Recurrent Pericarditis. Journal of the American College of Cardiology, 75(1), 76–92. https://doi.org/10.1016/j.jacc.2019.11.021

Ferraro, R., Latina, J. M., Alfaddagh, A., Michos, E. D., Blaha, M. J., Jones, S. R., Sharma, G., Trost, J. C., Boden, W. E., Weintraub, W. S., Lima, J. A. C., Blumenthal, R. S., Fuster, V., & Arbab, -Zadeh Armin. (2020). Evaluation and Management of Patients With Stable Angina: Beyond the Ischemia Paradigm. Journal of the American College of Cardiology, 76(19), 2252–2266. https://doi.org/10.1016/j.jacc.2020.08.078

Groenewegen, A., Rutten, F. H., Mosterd, A., & Hoes, A. W. (2020). Epidemiology of heart failure. European Journal of Heart Failure, 22(8), 1342–1356. https://doi.org/10.1002/ejhf.1858

Joshi, P. H., & de Lemos, J. A. (2021). Diagnosis and Management of Stable Angina: A Review. JAMA, 325(17), 1765–1778. https://doi.org/10.1001/jama.2021.1527

Palo, K. E. D., & Barone, N. J. (2020). Hypertension and Heart Failure: Prevention, Targets, and Treatment. Heart Failure Clinics, 16(1), 99–106. https://doi.org/10.1016/j.hfc.2019.09.001

Slivnick, J., & Lampert, B. C. (2019). Hypertension and Heart Failure. Heart Failure Clinics, 15(4), 531–541. https://doi.org/10.1016/j.hfc.2019.06.007

Vogel, B., Claessen, B. E., Arnold, S. V., Chan, D., Cohen, D. J., Giannitsis, E., Gibson, C. M., Goto, S., Katus, H. A., Kerneis, M., Kimura, T., Kunadian, V., Pinto, D. S., Shiomi, H., Spertus, J. A., Steg, P. G., & Mehran, R. (2019). ST-segment elevation myocardial infarction. Nature Reviews Disease Primers, 5(1), Article 1. https://doi.org/10.1038/s41572-019-0090-3

Zhang, Q., Wang, L., Wang, S., Cheng, H., Xu, L., Pei, G., Wang, Y., Fu, C., Jiang, Y., He, C., & Wei, Q. (2022). Signaling pathways and targeted therapy for myocardial infarction. Signal Transduction and Targeted Therapy, 7(1), Article 1. https://doi.org/10.1038/s41392-022-00925-z

SUBJECTIVE DATA:

The patient is B.F, a 58-year-old Caucasian male.

Chief Complaint (CC): troubling chest pain for one month.

History of Present Illness (HPI):

B.F is a 58-year-old Caucasian male presenting with troubling chest pain for the last one month. The pain occurs right in the middle of his chest and he describes it affirmatively as a tight, uncomfortable feeling that is currently at zero, on a pain scale of 0-10. However, during the previous episodes when he was experiencing the pain, he rates it at 5/10 and states that it is not crushing or burning.

For the last month, he has had 3 episodes. The first episode started with physical activity, while he was doing his yard work whereas the second episode started when he was taking stairs at work. All these episodes last for a few minutes and they all feel the same. To whatever extent, the pain does not radiate to the neck, shoulder, back, or even to the arm and is not associated with food intake. It is aggravated by physical activity and relieved by laying down with a brief rest but denies taking any medication for the chest pain. These manifestations are associated with hypertension and hyperlipidemia. However, he denies regular blood pressure monitoring, any coronary artery disease, or previous chest pain treatments. His medications are still current and unchanged and no new allergies are noted.

Medications: Current medications include, metoprolol 100 mg PO once daily, atorvastatin 20 mg PO once daily, omega 3 fish oil 1200mg PO once daily. He occasionally takes over-the-counter medications particularly Tylenol or Motrin when having headaches. Denies aspirin use. Previously had a heavy EKG but the one done 3 months ago was normal. He sees his primary care provider every 6 months.

Allergies: He has no known food and drug allergies although he experiences nausea and vomiting when taking codeine.

Past Medical History (PMH): A known stage 2 hypertensive patient since last year. He was also diagnosed with hyperlipidemia last year.

Past Surgical History (PSH): He declines any surgeries or any blood transfusion.

Sexual/Reproductive History: Sexually active.

Personal/Social History: Drinks 2 to 3 beers per week although he does not use tobacco or illicit drugs. Has not had a regular exercise for 2 years. Unsure of salt intake. Diet mainly consists of granola bars, turkey subs, grilled meat, and veggies. Daily water intake is an average of a liter. No unusual stress was noted. Married with two children, the wife is 50 years old and well.

Immunization History: His influenza vaccination is up to date while the last dose of TDAP was 10/2014.

Significant Family History: Father died at 75 years of age due to colon cancer. He also had

hypertension, hyperlipidemia, and obesity. His mother is an 80-year-old type 2 diabetic and hypertensive. His brother died at age 24 following a motor vehicle accident. His sister is 52 years old but has hypertension and type 2 diabetes. Maternal grandfather died at 54 years following a heart attack while maternal grandmother died at 65 years due to breast cancer. Paternal grandfather died at 85 years due to “old age” while paternal grandmother died at age 78 as a result of pneumonia. He healthy son and an asthmatic daughter aged 26 and 19 years respectively.

 Review of Systems:

General: denies any fever, fatigue, increased sweating, weight loss, or any recent illness.

            Cardiovascular/Peripheral Vascular: denies breathlessness, dizziness, and awareness of the heartbeat.

            Respiratory: No shortness of breath, denies cough

            Gastrointestinal: No nausea, vomiting, diarrhea, constipation, or abdominal pain.

            Musculoskeletal: No backpains, no joint pains

            Psychiatric: No depression, anxiety, or delirium.

Dermatological: No skin changes, rashes, or lesions.

OBJECTIVE DATA:

Physical Exam:

Vital signs: blood pressure  145/87 mmHg (left arm) and 145/89 mmHg (right arm), mean arterial blood pressure- 107 mmHg. Temperature- 37.6 degrees Celsius, heart rate-108 b/min, respiratory rate-19 breaths/min, oxygen saturation- 98% on rom air.

General: A middle-aged Caucasian male, alert, oriented, well-groomed, not in any form of distress, and has good nutrition and hydration status. Good oral hygiene, no cyanosis, no pallor, no jaundice, no lymphadenopathy, and no peripheral edema.

Cardiovascular/Peripheral Vascular: Normoactive precordium, S1, S2 heard without murmurs or rubs. Point of maximal impulse displaced laterally. S3 was noted in the mitral area. Right side carotid bruit. JVP 3 cm above the sternal angle. Left carotid pulse without a thrill, 2+. Right carotid pulse with bruit and thrill, 3+. Brachial, radial, femoral pulses without a thrill, 2+. Popliteal, posterior tibial, and dorsalis pedis pulses without a thrill, 1+. Capillary refill of all the extremities, 2 seconds.

Respiratory: Chest moving with respiration, symmetrical with no obvious surgical scars or lesions on inspection. Trachea centrally located with no obvious masses/tenderness on palpation. Resonant on percussion. Vesicular breath sounds in the upper lobes and right middle lobe. Fine crackles/rales in posterior bases of right and left lungs.

Gastrointestinal: The abdomen was moving with respiration, symmetrical, of normal contour and fullness with no visible scars or lesions on inspection. No tenderness both on deep and light palpation, liver span is 7 cm in the MCL and 1 cm below the right costal margin. Tympanic on percussion. The spleen and bilateral kidneys are impalpable. Normoactive bowel sounds in all the quadrants and no abdominal bruit on auscultation.

Musculoskeletal: Normal muscle bulk, tone, power grade 5 in all the groups, and normal reflexes.

Neurological: The GCS – 15/15, oriented to time, place, and person, intact memory, all cranial nerves intact, intact motor and sensory function, follows commands,

Skin: Warm, dry, pink, and intact. No skin tenting.

Diagnostic Test/Labs:

EKG- regular sinus rhythm, no ST changes. Fasting blood sugar and HbA1c to rule out diabetes given his family history. Additionally, he requires a lipid profile to evaluate the current levels. Liver function tests to check the liver function, complete metabolic panel to identify any underlying electrolyte abnormalities, complete blood count as well as cardiac enzymes, and brain natriuretic peptide to rule out myocardial infarction. Imaging studies include Doppler ultrasound to assess peripheral pulses, chest x-ray to check for any abnormal opacifications, and echocardiography to determine the ejection fraction or any structural lesions of the heart. Finally, CT angiography to detect any carotid diseases.

ASSESSMENT: B.F is a 58-year-old Caucasian male known hypertensive and hyperlipidemia patient on metoprolol, atorvastatin, and omega 3 fish oil, who presents with a one-month history of chest pain with exertion and upon climbing stairs although non-radiating but relieved by rest. He has a significant family history of metabolic syndrome, and he is physically inactive. On examination, the point of maximal impulse is displaced laterally, a third heart sound at the mitral area and diminished peripheral pulses, right carotid bruit and thrill as well as fine crackles/rales on the basal zones of both lungs.

Priority diagnoses:

• Angina pectoris.
• Bilateral basal crackles.
• Inactive lifestyle.

Differential Diagnoses: The differential diagnoses include coronary artery disease with stable angina. Coronary artery disease is an ischemic heart disease caused by the narrowing of coronary arteries resulting in a reduction in blood flow to the cardiac muscle, ultimately leading to an imbalance in coronary oxygen supply and demand (Parsons et al., 2018). Approximately 90%, of coronary heart disease, is due to coronary arteriosclerotic arterial obstruction and hyperlipidemia which is true in this patient. The patient also has stable angina evidenced by retrosternal chest pain n exertion but relieved by rest (Gillen & Goyal, 2021). Similarly, the chest pain could be a result f a silent non-ST elevated myocardial infarction (Cohen & Visveswaran, 2020).

Additionally, the patient is having uncontrolled hypertension evidenced by persistently elevated blood pressure despite being on medication. Periodic episodes of headache could also point toward uncontrolled hypertension (Oparil et al., 2018). Mr. B. F could also be having heart failure simply because he has an S3 gallop, bilateral crackles/rales, displaced apex beat in addition to risk factors such as hypertension and hyperlipidemia (Schwinger, 2021). Similarly, the patient could be having asymptomatic peripheral vascular disease. He has carotid bruit, thrill, and diminished peripheral pulses.

References

Cohen, M., & Visveswaran, G. (2020). Defining and managing patients with non-ST-elevation myocardial infarction: Sorting through type 1 vs other types. Clinical Cardiology, 43(3), 242–250. https://doi.org/10.1002/clc.23308

Gillen, C., & Goyal, A. (2021). Stable Angina. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559016/

Oparil, S., Acelajado, M. C., Bakris, G. L., Berlowitz, D. R., Cífková, R., Dominiczak, A. F., Grassi, G., Jordan, J., Poulter, N. R., Rodgers, A., & Whelton, P. K. (2018). Hypertension. Nature Reviews. Disease Primers, 4(1), 18014. https://doi.org/10.1038/nrdp.2018.14

Parsons, C., Agasthi, P., Mookadam, F., & Arsanjani, R. (2018). Reversal of coronary atherosclerosis: Role of lifestyle and medical management. Trends in Cardiovascular Medicine, 28(8), 524–531. https://doi.org/10.1016/j.tcm.2018.05.002

Schwinger, R. H. G. (2021). Pathophysiology of heart failure. Cardiovascular Diagnosis and Therapy, 11(1), 263–276. https://doi.org/10.21037/cdt-20-302

Photo Credit: [Squaredpixels]/[E+]/Getty Images

Take a moment to observe your breathing. Notice the sensation of your chest expanding as air flows into your lungs. Feel your chest contract as you exhale. How might this experience be different for someone with chronic lung disease or someone experiencing an asthma attack?

In order to adequately assess the chest region of a patient, nurses need to be aware of a patient’s history, potential abnormal findings, and what physical exams and diagnostic tests should be conducted to determine the causes and severity of abnormalities.

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

To Prepare

• Review this week’s Learning Resources and the Advanced Health Assessment and Diagnostic Reasoning media program and consider the insights they provide related to heart, lungs, and peripheral vascular system.
• Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation with the Shadow Health platform. Review the examples also provided.
• Review the DCE (Shadow Health) Documentation Template for Focused Exam: Chest Pain found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
• Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
• Review the Week 7 DCE Focused Exam: Chest Pain Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
• Consider what history would be necessary to collect from the patient.
• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

DCE Focused Exam: Chest Pain Assignment:

Complete the following in Shadow Health:

• Cardiovascular Concept Lab (Required)
• Respiratory(Recommended but not required)
• Cardiovascular (Recommended but not required)
• Episodic/Focus