Assignment 1: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System NURS 6512N-32
ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: Assignment 1: Digital Clinical Experience: Assessing the Heart Lungs and Peripheral Vascular System NURS 6512N-32
Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation
Name: Mr. J.M. Age: 38 years Sex: Male
SUBJECTIVE DATA:
Chief Complaint (CC): “I have sporadic chest pain”
History of Present Illness (HPI):Mr. J.M., a 38-year-old African American man, presented to the emergency department complaining of sporadic chest pain for the previous month. The pain is usually in the center of the body and radiates to the left arm. Since the last month, he has had three episodes, each lasting several minutes. The pain is currently at 0 on a scale of 0 to 10, though it is usually at 5 at its worst. The discomfort and tightness are typical of the pain. Activities like climbing stairs and yardwork aggravate it, while brief periods of rest relieve it. He has not taken any pain medications.
In research, the literature review describes existing knowledge about the topic, reveals gaps and further research questions to be answered, and provides a rationale for engaging in a new study. The literature review provides evidence to answer clinical questions and make informed decisions in evidence-based practice. Quality improvement studies also begin with searching the literature to gather available knowledge about a problem and explore interventions used in other settings. The appearance of journals that predatory publishers publish has introduced the danger that reviews of the literature include inade
quate, poorly designed, and low-quality information being used as “evidence”—raising the possibility of risky and harmful practice. A helpful literature review requires searching various reliable and credible databases such as MEDLINE (through PubMed or Ovid) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), among others relevant to the topic. The ease of searching using a web browser (now commonly referred to as “googling”) has increased the risk of finding sources published in predatory. Low-quality journals that have not met the standards of research and scholarship can be regarded as credible and reliable evidence ( Oermann, Wrigley, Nicoll, Ledbetter, Carter-Templeton, & Edie, 2021).
Medications: Reports taking Lopressor 100mg PO once daily for hypertension and Lipitor 20mg PO once daily for hyperlipidemia as well as fish oil 1000mg PO twice daily.
Allergies: None
Past Medical History (PMH): Reports hypertension and hypercholesterolemia. No previous hospitalizations or blood transfusions. Denies prior chest pain treatment. Poor blood pressure monitoring both at home. Denies regular blood pressure checks at the pharmacy and drug store. Reports a recent EKG test that was normal. His last visit to a healthcare provider was three months ago.
Past Surgical History (PSH): No previous surgeries.
Sexual/Reproductive History: Heterosexual.
Personal/Social History: Has lead a relatively stress-free existence. A liter of water per day is recommended. Every day, he consumes two cups of coffee. Denies routine regular physical activity and hasn’t exercised in over two years. Reports moderate alcohol consumption of 2 to 3 drinks per week, primarily on weekends, but no use of tobacco or illegal drugs. His typical breakfast consists of a granola bar and an instant breakfast shake, his lunch consists of a turkey sub, and his dinner consists of grilled meat with vegetables.
Immunization History: All immunization up to date. The last COVID-19 vaccine was February this year, the last Tdap was May 2022 and the last influenza was January 2022.
Significant Family History: His mother is 65 years old and hypertensive while the father is 70 years old and obese. The grandmother died at 77 years due to a heart attack while the grandfather is 85 but suffered a stroke at 80 years. He has two daughters all alive and well.
Review of Systems:
General: Denies fever, changes in weight, chills, fatigue, night sweats, and palpitations.
Cardiovascular/Peripheral Vascular: No edema, easy bruising, angina, or easy bleeding.
Respiratory: No difficulty in bleeding, sputum, cough, or shortness of breath.
Gastrointestinal: Denies alteration in bowel habits, abdominal pain and nausea, and vomiting
Musculoskeletal: No back pains, joint pains, and muscle weakness.
Psychiatric: No anxiety, depression, delusions, or hallucinations
OBJECTIVE DATA:
Physical Exam:
Vital signs: Temperature- 98.5 F, pulse 80 beats per min, respiratory rate- 19 breaths per minute, blood pressure- 132/86 mmHg, saturation- 92% on room air, height 70. 86 inches, weight 251 lbs. BMI- 29.
General: A young African American male, well kempt and groomed, and appropriate for his stated age. Not in any obvious distress, good body built and well hydrated. No pallor, finger clubbing, splinter hemorrhages, jaundice, cyanosis, lymphadenopathy, or peripheral edema.
Cardiovascular/Peripheral Vascular: Nondistended neck veins (JVP less than 4cm above sternal angle), right carotid pulse 3+ with a thrill and bruit, left carotid pulse 2+ with no thrill or bruit, right and left brachial and radial arteries pulses 2+ with no thrills, right and left femoral arteries pulses 2+ with no thrills and bruits, right and left popliteal arteries pulses 1+ with no thrills, right and left tibial and dorsalis pedis pulses 1+ with no thrills, no renal, iliac and abdominal aorta bruits, and capillary refill is less than 3 seconds in all the digits. Precordium is brisk and tapping. The point of maximal impulse is displaced laterally and less than 3 cm, with a heave but no thrill. S1, S2, and S3 were heard with gallops, no murmurs.
Respiratory: Symmetric chest, moves with respiration with no obvious scars or masses on inspection. the trachea is central, with equal chest expansion, no tenderness or palpable masses, and equal tactile fremitus on palpation. Resonant on percussion. Good air entry and vesicular breath sounds in all lung zones, and no wheezes or rhonchi on auscultation.
Gastrointestinal: Nondistended, moves with respiration, symmetric, normal contour and fullness, umbilicus everted and no visible distended veins, striae, or scars. No tenderness or palpable masses on light and deep palpation. The liver is palpable 2 cm below the right costal margin. Liver span 8 cm. Spleen and both kidneys are impalpable. Tympanic on percussion, no shifting dullness or fluid thrill. No friction rubs over the liver and spleen.
Musculoskeletal: Normal muscle bulk, power of 5/5 in all muscle groups, normal reflexes, and range of movement across all joints.
Neurological: GCS 15/15, oriented to time place, and person, all cranial nerves and sensation intact, no neurological deficits noted, good bladder and bowel function.
Skin: No rashes, darkening, tenting, or nail changes.
Diagnostic Test/Labs: An EKG was done which revealed a sinus rhythm with no ST changes. Other critical tests include cardiac biomarkers particularly, troponin T/I, CK-MB, and myoglobin to exclude myocardial injury (Harskamp et al., 2019). Lipid profile and random blood sugar are required to check the level of lipid control and exclude diabetes mellitus respectively. Additionally, LDH to assess for cell necrosis, BNP to exclude concurrent heart failure, and inflammatory markers especially CRP for prognostication. Similarly, complete blood count with differential, urea creatinine, and electrolytes as well as liver function tests are required as a baseline for medication. Imaging tests include a transthoracic echocardiogram to assess left ventricular function, detect any wall motion abnormalities and identify any complications (Harskamp et al., 2019). Finally, a cardiac CT with IV contrast may be required to rule out differentials such as pulmonary embolism and aortic dissection.
ASSESSMENT:
Mr. J.M. is a 38-year-old African American male, known patient with hyperlipidemia and hypertension who presents with complaints of sporadic centrally located chest pain that radiates to the left arm. The pain is usually aggravated by exertion but relieved by rest with a history of physical inactivity. On examination, the right carotid artery pulse is increased with a bruit and thrill, the apex is displaced laterally, and S1, S2, and S3 are heard with gallops but no murmurs.
Main Diagnosis- The primary diagnosis is stable angina. Mr. J.M. presents with retrosternal chest pain that is tight and uncomfortable and that radiates to the left arm. This is characteristic of angina. However, these symptoms are worsened by exertion but relieved by rest which is a distinct feature of stable angina (Rousan & Thadani, 2019). According to Rousan and Thadani (2019), atherosclerosis is the most common etiology of this condition. Mr. J.M. has classic risk factors for atherosclerosis including arterial hypertension, hyperlipidemia, alcohol consumption, and overweight as well as a family history of cardiovascular events.
Differential diagnosis
Elevated non-ST segmented myocardial infarction- A myocardial infarction is an acute myocardial injury caused by ischemia that results in tissue necrosis. This condition is also characterized by dull and tight retrosternal chest pain that is exacerbated by exertion and radiates to the left arm, shoulder, neck, or jaw. An atherosclerotic event can also cause a myocardial infarction. However, the absence of ST changes on the EKG suggests NSTEMI (Cohen & Visveswaran, 2020).
Hypertension and hyperlipidemia- Mr. J.M. has previous history of hypertension on metoprolol and hyperlipidemia on Lipitor. Furthermore, lateral displacement of the apex beat as well as a heave suggest left ventricular hypertrophy which is usually a consequence of arterial hypertension (Oparil et al., 2018).
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
Harskamp, R. E., Laeven, S. C., Himmelreich, J. C., Lucassen, W. A. M., & van Weert, H. C. P. M. (2019). Chest pain in general practice: a systematic review of prediction rules. BMJ Open, 9(2), e027081. https://doi.org/10.1136/bmjopen-2018-027081
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
Rousan, T. A., & Thadani, U. (2019). Stable angina medical therapy management guidelines: A critical review of guidelines from the European Society of Cardiology and National Institute for Health and Care Excellence. European Cardiology, 14(1), 18–22. https://doi.org/10.15420/ecr.2018.26.1
Cardiovascular disease (CVD) is the largest cause of death worldwide. Accounting for 610,000 deaths annually (CDC, 2017), CVD frequently goes unnoticed until it is
too late. Early detection and prevention measures can save the lives of many patients who have CVD. Conducting an assessment of the heart, lungs, and peripheral vascular system is one of the first steps that can be taken to detect CVD and many more conditions that may occur in the thorax or chest area.
This week, you will evaluate abnormal findings in the area of the chest and lungs. In addition, you will appraise health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system.
ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: Assignment 1: Digital Clinical Experience: Assessing the Heart Lungs and Peripheral Vascular System NURS 6512N-32
Week 7
Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation
SUBJECTIVE DATA:
Chief Complaint (CC): “I have been having some troubling chest pain in my chest for some time now.”
A 58-year-old Caucasian male arrives at the clinic with a history of current illness (HPI). “I’ve been having some troubling chest pain in my chest for some time now,” the patient says. The patient also reports that he has been experiencing chest pains on a regular basis, particularly when exerting himself in the yard or overeating. The pain is located in the mid sternum region, and he rates it as a 5/10 whenever he feels it. His pain is described as “tight and uncomfortable.” The pain does not spread. The pain is short-lived and goes away when the patient rests. His most recent episode of chest pain occurred three days ago at a restaurant as a result of a large dinner. He did not believe the pain required immediate attention; however, he expresses concern due to the three episodes within a month, and thus the heart must be examined. He also claims that when he is inactive, his legs cramp slightly. He denies having dyspnea, GERD, indigestion, or heartburn. At the time of the assessment, he reports no chest pain.
Medications: The patient has a medical history of using omega three on a daily basis from fish oil, atorvastatin (20 mg) on a daily basis, for high cholesterol for the last one year, occasional use of ibuprofen. The patient takes metoprolol, 100 mg for high blood pressure.
Allergies: The patient confirms some allergies
Past Medical History (PMH): The patient last visited a primary care provider last three months ago. The patient has had treatments for high cholesterol and high blood pressure but reports no incidences of hospitalization.
Past Surgical History (PSH): no past surgical history was reported
Personal/Social History: while the patient denies using tobacco, he agrees that he consumes alcohol moderately, with the patient using two to three alcoholic drinks every week. The patient does not engage in any regular exercise in recent times as the last regular exercise was done the last time two years ago.
Immunization History: No immunization data was presented.
Significant Family History: The late father had obesity, hypertension, and hyperlipidemia, sister has diabetes type 2 and hypertension. Mother had a heart attack.
Review of Systems
General: The patient reports a recent weight gain since the loss of his bike. Denies any sweats, night sweats, chills, fever, and fatigue
Cardiovascular/Peripheral Vascular: no edema, orthopnea, nor chest pain
Respiratory: no pneumonia, dyspnea, hemoptysis, wheezing, and cough
Gastrointestinal: denies ulcers, eating disorders, hepatitis, constipation or
abdominal pain
Musculoskeletal: no fracture, pain or stiffness, joint swelling or back pain
Psychiatric: No suicidal attempts/ideation, sleeping difficulties, anxiety or
depression
OBJECTIVE DATA:
Physical Exam:
Vital signs: BP : 105/78; T: 98.3; P: 117; R:22; Weight: 124lbs; Height: Height 5’
General Survey: The patient is a 58-year-old who demonstrates alertness and is proper orientation. He has clear speech and does not appear to be in any acute distress.
Cardiac: S1, S2, gallops do not have rubs or murmurs. The PMI has a lateral displacement. S3 is appearing at the mitral area.
Peripheral Vascular: He has a carotid bruit on the right side. His JVP appears above the sternal angle at 3cm. He has 3+ thrill at the right carotid. The pulse in the left carotid lacks thrill and has a 2+ expected amplitude. The femoral, radial, and brachial pulses lacked bruit ar 2+. Dorsalis pedis, tibial and popliteal pulses lack thrill at 1+. The capillary refill occurs below 3 seconds at all the four extremities.
Respiratory: The patient breathes quietly and unlabored. His breath sounds showed clarity to auscultation around the RML and the upper lobes. The patient produces fine rales/crackles in the bases of posterior regions of the left and right lungs.
Gastrointestinal: The abdomen is soft, round with a non-tender appearance. All four quadrants produce normoactive sounds. The abdomen lacks bruits. Both palpitations did not show tenderness. Tympany exists throughout the abdomen. The patient’s liver’s length is 7cm and 1 cm at the MCL and below the right costal margin, respectively. The bilateral kidneys and the spleen lack palpability.
Neuro: The patient is oriented everywhere and alert. He does not disobey commands. All of his extremities move when instructed.
Skin: The skin is intact, pink, and dry. It does not have tenting.
EKG: The interpretation of the EKG shows regular sinus rhythm. There are no changes in the ST as well. .
Diagnostics
The patient should undergo an X-ray examination of the chest (Ball et al., 2017). He should also have a fasting lab workup that includes liver function, BNP, CBC, Hgb A1C, electrolytes, cardiac enzymes, and lipid profile tests. These tests can be instrumental in confirming the exact illness troubling Mr. Foster.
ASSESSMENT
Priority diagnosis: Coronary artery disease with stable angina
- Congestive heart failure
- Carotid artery disease
- GERD
Plaque buildup in the coronary arteries, which provide blood to the heart, may be causing the patient’s angina or chest pain (Shahjehan & Bhutta, 2020). Myocardial oxygenation is impaired by coronary artery disease, which is among the most common diseases. Cardiovascular illness is at risk due to the patient’s long-standing hyperlipidemia and hypertension, as well as his or her family’s history of heart attacks (Regmi & Siccardi, 2020).
Congestive heart failure: The patient reported mid-sternum chest pain that was tight and lasting five minutes to half an hour, and that it might be induced by exertion. An S3 gallop and a thrill and bruit on the right side were also present in the patient (Colyar, 2015). These signs and symptoms point to heart failure, a condition that severely restricts one’s ability to engage in strenuous physical exercise. Resting comfortably is possible for the patient with this condition. However, indications of heart failure are triggered by routine physical exercise (Dains et al., 2019).
Because of the patient’s history of elevated cholesterol, one of the possible diagnoses is carotid artery disease (Deeb et al.,2019). There is also a family history of both diabetes and high blood pressure in the patient’s family. Additional risk factors for carotid disease include the patient’s inability to exercise and a history of smoking.
When the patient complained of chest pain, it was thought that he might have GERD, which was on the list of possibilities for a differential diagnosis with heartburn. One of the risk factors is the patient’s consumption of alcohol.
Previous diagnosis
High blood pressure-controlled through the use of Lopressor
Hyperlipidemia: The patient is using atorvastatin to control the condition
Learning Objectives
Students will:
- Evaluate abnormal cardiac and respiratory findings
- Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system
Learning Resources
This section of Chapter 8 describes the anatomy of the chest wall, pulmonary, and cardiovascular systems. Section 1 also explains how to properly conduct examinations of these areas.
Assignment 1: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System
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 (Recommended but not required)
- Abdominal Concept Lab (Recommended but not required)
- Episodic/Focused Note for Focused Exam: Chest Pain
Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 7 Day 7 deadline.
Submission and Grading Information
By Day 7 of Week 7
- Complete your Focused Exam: Chest Pain DCE Assignment in Shadow Health via the Shadow Health link in Blackboard.
- Once you complete your Assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding Assignment in Blackboard for your faculty review.
- (Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You can find instructions for downloading your lab pass here: https://link.shadowhealth.com/download-lab-pass
- Once you submit your Documentation Notes to Shadow Health, make sure to copy and paste the same Documentation Notes into your Assignment submission link below.
- Download, sign, date, and submit your Student Acknowledgement Form found in the Learning Resources for this week.
Grading Criteria
To access your rubric:
Week 7 Assignment 1 DCE Rubric
Submit Your Assignment by Day 7 of Week 7
To submit your Lab Pass:
Week 7 Lab Pass
To participate in this Assignment:
Week 7 Documentation Notes for Assignment 1
To Submit your Student Acknowledgement Form:
Submit your Week 7 Assignment 1 DCE Student Acknowledgement Form
Assignment 2: Lab Assignment (Optional): Practice Assessment: Cardiac and Respiratory Examination
It is crucial to diagnose cardiac and respiratory conditions early due to the critical nature of these organs. Before a condition can be diagnosed, an examination must be conducted. Properly conducting a cardiac and respiratory examination requires detailed knowledge of the examination procedure and experience in performing this assessment.
In preparation for the Comprehensive (Head-to-Toe) Physical Assessment due in Week 9, it is recommended that you practice performing a cardiac and respiratory examination this week.
Note: This is an optional practice physical assessment.
To Prepare
- Arrange an appropriate time and setting with your volunteer “patient” to perform a cardiac and respiratory examination.
- Download and review the Cardiac and Respiratory Checklists provided in this week’s Learning Resources as well as review the Seidel’s Guide to Physical Examination online media.
- Ensure that you have a stethoscope to perform the examination.
Optional Lab Assignment
- Perform the cardiac and respiratory examination. Be sure to cover all of the areas listed in the checklist and to use the equipment appropriately.
What’s Coming Up in Week 8?
Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
Next week, you will explore how to accurately assess the musculoskeletal system.
Week 8 Required Media
Photo Credit: [fergregory]/[iStock / Getty Images Plus]/Getty Images
Next week, you will need to view several videos and animations in the Seidel’s Guide to Physical Examination prior to completing your Discussion. There are several videos of various lengths. Please plan ahead to ensure you have time to view these media programs to complete your Discussion on time.
Chief complaint: “I have been having some trouble with chest pain for the past month
History of presenting illness: Mr. Foster presents at the emergency department complaining of chest pain in the mid-sternum region. It is intermittent, tight, and uncomfortable lasting for a short time. It is of acute onset aggravated by meals and exertion and relieved by rest. However, the pain does not radiate. It is associated with mild leg cramping the patient denies coughing, shortness of breath, indigestion, heartburn, jaw pain, dizziness weakness, nausea, vomiting, diarrhea, anxiety, and emotional stress.
Past medical history: the patient has hypertension, hyperlipidemia, and diabetes mellitus
Surgical history: none
Allergies: he is allergic to dust, fur, and cold weather. He develops a skin rash and itchiness and relieves it by taking prednisolone. He has no food and drug allergy.
Medication: metformin 1g PO BID, amlodipine 10mg PO OD, atorvastatin 20mg PO OD
Immunization: the patient’s immunization schedule is up to date. His last influenza and pneumococcal vaccines are six months and three months ago respectively. He is yet to get a tetanus toxoid booster.
Social history: Mr. foster works as an operations manager in a bank. She has studied up to a master’s degree in
finance. He is married, has two children, and stays with them. He enjoys reading novels and watching documentaries. His diet includes grilled red meat about five times a week, vegetables, and sandwiches. Occasionally, he takes fast food for lunch on a busy day with 1-2cups of coffee a day. He smokes at least cigarettes per day. He takes two bottles of beer daily and a bottle of whisky over the weekend. He does not engage in physical exercise.
Family history: the patient is the firstborn in a family of three siblings. His mother has hyperlipidemia, hypertension, and osteoarthritis. His father has obesity, diabetes mellitus, coronary heart disease, and hypertension. His paternal grandfather died six years ago due to acute myocardial infarction and his grandmother died ten years ago due to diabetes mellitus. His maternal grandparents are living with senile dementia. His younger sister 40 years has hypertension. His younger brother, 35years old has hyperlipidemia and diabetes mellitus. His children have no major chronic illnesses. However, there is no history of lung or breast cancer.
Review of systems:
General: the patient denies fatigue, weight loss, night sweats, and fever.
HEENT: The patient denies headache, dizziness, eye itchiness, ear pain, sore throat, and running nose.
Respiratory system: the patient denies coughing, running nose, difficulties in breathing, wheezing, and sputum production.
Gastrointestinal system: the patient denies abdominal pain, reflux, heartburn, nausea, vomiting, diarrhea, constipation, and Malena stool.
Genitourinary system: the patient denies hematuria, dysuria, polyuria, flank pain, vaginal discharge, dyspareunia, and urine incontinence.
Neurological: the patient denies paralysis, numbness of extremities, facial droop, and tingling sensation.
Musculoskeletal system: the patient reports mild cramping of the legs. However, he denies joint pain, muscle pain, stiffness, muscle spam, fracture, and dislocation.
Hematological system: the patient denies easy bruising, frequent infections, fever, and bleeding tendencies.
Lymphatic system: the patient denies lower limb edema, recurring infections, skin fibrosis, and lymph nodes.
Skin: the patient denies skin rash, stretch marks, and itchiness.
Endocrine: patient denies weight fluctuation, weakness, fatigue, heat and cold intolerance, and mood swings.
Objective Data
General examination: the patient is alert and oriented. he has a clear speech sitting comfortably with no acute distress.
Vitals: blood pressure 164/88, pulse rate 94beats per minute, the temperature at 36.5, height 151cm, weight 78kg, and BMI 34.21kg/m2.
Cardiovascular system: S1 S2 noted with no murmurs or rubs. S3 is noted at the mitral area and the PMI is displaced laterally at the mitral area.
Peripheral vascular: there is no JVD present. JVP is 3cm above the sternal angle. The left carotid has no bruit. There is a right carotid bruit with a 3+ thrill. The brachial, femoral, and radial pulses have no thrill. The capillary refill is less than 3sec in all four extremities.
Respiratory: the breathing is quiet and unlabored. The breath sounds are clear to auscultation in the upper and lower lobes. There are fine crackles in the posterior base of the right and left lungs.
Gastrointestinal: the abdomen is soft, round, and non-tender with normal-active bowel sounds in all the four quadrants. There are no abdominal bruits and tenderness to light and deep palpation. The liver span is 7cm at the MCL and 1cm below the costal margin. There is a tympanic percussion note throughout. The spleen and bilateral kidneys are not palpable.
Skin: the skin is warm, dry, pink, and intact. There is no tenting and sweating.
Neurological: the patient is alert and oriented. She follows commands, moves all the extremities, and the gross cranial nerves are intact.
Musculoskeletal: The patient moves all the extremities.
Psychiatric: the patient is cooperative, maintains eye contact, and has a normal affect.
EKG: the patient has a regular sinus rhythm. There are no ST changes.
Assessment
The patient presents with chest pain and mild leg cramping on exertion. He has hypertension, hyperlipidemia, and diabetes mellitus. The patient is obese and has diminished carotid pulse and bruits. He has an S3 in the mitral region. He leads a sedentary lifestyle. He smokes and takes alcohol every day. He has a positive family history of diabetes mellitus, hypertension, hyperlipidemia, myocardial infarction, and coronary heart disease. The differential diagnoses are angina pectoris, coronary heart disease, and congestive cardiac failure.
Angina pectoris is an imbalance of myocardial blood supply and demand. It is common in patients with coronary arteries. The main presenting complaint is chest pain. the pain is in the epigastric region or retro-sternal region and it feels very tight. The pain is precipitated by exertion, meals, and emotional stress lasting for about 5minutes. The patient does not change in respiration. Risk factors are atherosclerosis, metabolic syndrome, severe anemia, and hyperthyroidism (Webb, C. M., & Collins, P. 2021). This is the probable diagnosis because the patient presents with intermittent chest pain on exertion and after meals. He has metabolic syndrome because of obesity, hyperlipidemia, hypertension, and diabetes mellitus. Additionally, he has atherosclerosis because of the reduced carotid pulses and bruits.
Coronary heart disease is a disease of the blood vessels characterized by endothelial dysfunction, vascular inflammation, build-up of lipids, cholesterol, and calcium and cellular debris in the vessel wall. This causes plaque formation, luminal obstruction, and reduced oxygen supply to the target organs. Clinical signs and symptoms are epigastric pain postprandial, neurological deficits, intermittent claudication, and weight loss (Cushman, et al, 2021). The patient often presents with hyperlipidemia, diminished carotid pulse and bruits, peripheral cyanosis, and gangrene. However, this is not the actual diagnosis because the patient does not have cyanosis, weight loss, and gangrene.
Congestive heart failure is the inability of the heart to pump blood at a rate that commensurates the demand of the metabolizing tissues. The patient presents with exertional dyspnea, orthopnea, edema, tachycardia, fatigue, oliguria, distended neck veins, wheezing, and hepatojugular reflux (Koehler, et al, 2021). However, this is not the actual diagnosis because the patient does not meet the Framingham criteria for heart failure. It comprises paroxysmal nocturnal dyspnea, neck vein distension, acute pulmonary edema, cardiomegaly, and S gallop.
Plan
Diagnostic tests
- Chest radiograph to rule out cardiomegaly or cardiomyopathy
- CT angiography demonstrates an anatomical assessment of the hemodynamic significance of coronary stenosis.
- Exercise stressing tests help evaluate the chest pain
- Cardiac enzymes rules out cardiomyopathy
- Complete blood count to rule out anemia
- A1C determines the patient’s diabetes control for three months
- The lipid profile checks the level of triglycerides.
Pharmacological treatment
- Aspirin 81mg PO OD
- Atorvastatin 40mg PO OD
- Losartan 50mg PO OD
- Nitroglycerine 6.5mg PO TDS
- Metformin 1g PO BD
Non-pharmacological
- Lifestyle modification
- Refer the patient to the physician and cardiologist
References
Cushman, M., Shay, C. M., Howard, V. J., Jiménez, M. C., Lewey, J., McSweeney, J. C., … & American Heart Association. (2021). Ten-year differences in women’s awareness related to coronary heart disease: results of the 2019 American Heart Association National Survey: a special report from the American Heart Association. Circulation, 143(7), e239-e248.
Koehler, J., Stengel, A., Hofmann, T., Wegscheider, K., Koehler, K., Sehner, S., … & Laufs, U. (2021). Telemonitoring in patients with chronic heart failure and moderate depressed symptoms: results of the Telemedical Interventional Monitoring in Heart Failure (TIM‐HF) study. European journal of heart failure, 23(1), 186-194.
Webb, C. M., & Collins, P. (2021). Medical management of anginal symptoms in women with stable angina pectoris: A systematic review of randomised controlled trials. International Journal of Cardiology, 341, 1-8.
Next Week
To go to the next week:
Week 8
Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Name: NURS_6512_Week_7_DCE_Assignment_1_Rubric
Description: To complete the Shadow Health assignments, it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions and the physical assessment areas. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Weeks 1 and 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score.
Name: NURS_6512_Week_7_DCE_Assignment_1_Rubric
Description: To complete the Shadow Health assignments, it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions and the physical assessment areas. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Weeks 1 and 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score.
| Excellent | Good | Fair | Poor | |
|---|---|---|---|---|
| Student DCE score
(DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.) Note: DCE Score – Do not round up on the DCE score. |
Points Range: 56 (56%) – 60 (60%)
DCE score>93
|
Points Range: 51 (51%) – 55 (55%)
DCE Score 86-92
|
Points Range: 46 (46%) – 50 (50%)
DCE Score 80-85
|
Points Range: 0 (0%) – 45 (45%)
DCE Score <79 No DCE completed. |
| 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: You should list these in bullet format and document the systems in order from head to toe. |
Points Range: 16 (16%) – 20 (20%)
Documentation is detailed and organized with all pertinent information noted in professional language. Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). |
Points Range: 11 (11%) – 15 (15%)
Documentation with sufficient details, some organization and some pertinent information noted in professional language. Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). |
Points Range: 6 (6%) – 10 (10%)
Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language. Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). |
Points Range: 0 (0%) – 5 (5%)
Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language. No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). or No documentation provided. |
| Objective Documentation in Provider Notes – this is to be completed in Shadow Health
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 Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1). |
Points Range: 16 (16%) – 20 (20%)
Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language. Each system assessed is clearly documented with measurable details of the exam. |
Points Range: 11 (11%) – 15 (15%)
Documentation with sufficient details and some organization; some abnormal and some normal assessment information described in mostly professional language. Each system assessed is somewhat clearly documented with measurable details of the exam. |
Points Range: 6 (6%) – 10 (10%)
Documentation with inadequate details and/or organization; inadequate identification of abnormal and pertinent normal assessment information described; inadequate use of professional language. Each system assessed is minimally or is not clearly documented with measurable details of the exam. |
Points Range: 0 (0%) – 5 (5%)
Documentation with no details and/or organization; no identification of abnormal and pertinent normal assessment information described; no use of professional language. None of the systems are assessed, no documentation of details of the exam. or No documentation provided. |
| Total Points: 100 |
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