Discussion: NURS 6512 Assessing the Heart, Lungs, and Peripheral Vascular System
Discussion NURS 6512 Assessing the Heart, Lungs, and Peripheral Vascular System
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SUBJECTIVE DATA:
Chief Complaint (CC): “I have sporadic chest pain”
History of Present Illness (HPI): Mr. J.M. is a 38-year-old African American male who presented to the emergency department with complaints of sporadic chest pain for the last one month. The pain is usually centrally located and radiates to the left arm. He has experienced 3 episodes since the last month with each episode lasting several minutes. Currently, the pain is at 0 on a scale of zero to 10 although it is generally at 5 at its worst. The pain is characteristically uncomfortable and tight. It is aggravated by activities such as climbing stairs and yardwork while brief episodes of rest relieve the pain. He has not taken any medications for the pain.
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 lived a relatively stress-free lifestyle. Regular water intake of about a liter per day. Drinks 2 cups of coffee daily. Denies routine regular physical activity and his last regular exercise was 2 years ago. Reports moderate alcohol consumption of about 2 to 3 drinks per week mostly on weekends but no tobacco or illicit drug use. His typical breakfast is a granola bar and instant breakfast shake, lunch turkey sub, and his dinner is typically grilled meat alongside 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
Non-ST segmented elevated myocardial infarction- Myocardial infarction refers to an acute myocardial injury caused ischemia that results in tissue necrosis. This condition also presents with a retrosternal chest pain that dull and tight, precipitated by exertion and radiates to the left arm, shoulder, neck or jaw. Myocardial infarction may also be precipitated by an atherosclerotic event. However, lack of ST changes on 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
Consider your breathing for a moment. Take note of how your chest expands as air enters your lungs. As you exhale, feel your chest contract. How may this experience differ for someone suffering from chronic lung disease or someone having an asthma attack?
To properly assess a patient’s chest region, nurses must be knowledgeable of the patient’s history, probable abnormal findings, and what physical exams and diagnostic tests should be performed to determine the reasons and degree of abnormalities.
In this Discussion, you’ll look at how a patient’s initial symptoms might lead to completely different diagnosis when further testing is done.
Please keep in mind that by the first day of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. In addition, rather than the typical narrative style Discussion posting structure, your Discussion post should be in the Episodic/Focused SOAP Note format. For further information, see Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources. Remember that all Episodic/Focused SOAP notes include specific data for each patient instance.
To get ready:
Concerning the case study you were assigned:
Consider the insights provided by this week’s Le
Please keep in mind that by the first day of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. In addition, rather than the typical narrative style Discussion posting structure, your Discussion post should be in the Episodic/Focused SOAP Note format. For further information, see Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources. Remember that all Episodic/Focused SOAP notes include specific data for each patient instance.
To get ready:
Concerning the case study you were assigned:
Consider the insights provided by this week’s Learning Resources.
Consider what information you would need to obtain from the patient.
arning Resources.
Consider what information you would need to obtain from the patient.
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Consider what physical exams and diagnostic testing might be necessary to learn more about the patient’s condition. How would the findings be used to make a decision?
Identify at least five probable conditions that could be considered in the patient’s differential diagnosis.
Note: Before you submit your first post, change the subject line from “Discussion – Week 6” to “Review of Case Study” and include the case study number you were allocated.
By Day 3
Using the episodic/focused note template provided in week 5 resources, post an episodic/focused note about the patient in the case study to which you were assigned. Provide literary evidence to support diagnostic testing that would be appropriate in each scenario. Explain why you chose each of the five probable conditions for the patient’s differential diagnosis.
Please keep in mind that you must complete your initial post before you may access and comment to your colleagues’ postings in this Discussion. Begin by clicking on the “Post to Discussion Question” option, then “Create Thread” to finish your first post. Remember that once you press the Submit button, you cannot delete or change your own posts, and you cannot publish anonymously. Please double-check your post before clicking the Submit button!
Read some of your coworkers’ responses.
By Day 6
Respond to at least two of your coworkers who were assigned different case studies than you on two different days. Examine the potential illnesses based on your colleagues’ differential diagnoses. Which of the conditions would you reject and why? Determine the most likely condition and explain your reasoning.
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.