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

Walden University NURS 6512 Assignment 1 Week 7: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System-Step-By-Step Guide

This guide will demonstrate how to complete the Walden University NURS 6512 Assignment 1 Week 7: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for NURS 6512 Assignment 1 Week 7: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System                     

Whether one passes or fails an academic assignment such as the Walden University NURS 6512 Assignment 1 Week 7: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for NURS 6512 Assignment 1 Week 7: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System                     

The introduction for the Walden University NURS 6512 Assignment 1 Week 7: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

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How to Write the Body for NURS 6512 Assignment 1 Week 7: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System                     

After the introduction, move into the main part of the NURS 6512 Assignment 1 Week 7: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for NURS 6512 Assignment 1 Week 7: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System                     

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for NURS 6512 Assignment 1 Week 7: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System                     

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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Review of Systems:

General:  Mr. Foster denies fatigue, dizziness, weakness, and fever. He reports gaining 20lbs in the past few years.

Cardiovascular/Peripheral Vascular: Negative for orthopnea, reports no edema in BLE. Denies feeling the heart  racing, skipping beats, or feeling flushed. vertigo

Respiratory: Positive for SOB with exercise and walking a flight of stair at work; denies cough or hemoptysisGastrointestinal: Denies changes in bowel or bladder routine. No diarrhea, constipation, or abdominal pain.

Gastrointestinal: Reports no issues with bladder and bowel.

Musculoskeletal: Denies any change in gait and balance.

Psychiatric: Denies feeling depressed

OBJECTIVE DATA:

Physical Exam:

Vital signs: BP 146/90 mmHg. Pulse rate at 104 beats per minute, respiratory rate at 19  per minute, temperature at 36.7, and oxygen  98% on RA.

General: Patient Alert and oriented , well groomed,in a pleasant mood. Sitting upright on an examination chair. No signs of current distress noted.

Cardiovascular/Peripheral Vascular: The heart sounds s1 and s2 with no murmurs. S3 rub is noted at the mitral area. There is no swelling or fluid retention. The JVP is 3cm above the sternal angle. There is no JVD present. The left carotid has no bruit while the right has a bruit. The right carotid has a thrill of 3+. Brachial, femoral, and popliteal pulses are without a thrill. Capillary refill is less than three seconds in all four extremities.

Gastrointestinal: The abdomen is soft, non-tender, and round with normal active bowel sounds in the four quadrants. There are no abdominal bruits. There is no 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. There is no organ enlargement.

Musculoskeletal: Able to move all extremities. No abnormal gait or imbalance noted.

Neurological:  Patient is Alert and Oriented. He follows all commands.

Skin: skin is intact with no abnormalities noted.

Diagnostic Test/Labs:  EKG, Complete lab count, Chest- Xray to rule out pneumonia, covid swab

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/Focused Note for Focused Exam (Required): 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.

Review of Systems:

General: Denies fever, chills, weight loss, increased sweating, recent illness, or fatigue.

HEENT: No blurring of vision, hearing problems, runny nose, sore throat, or difficulty in swallowing.

            Cardiovascular/Peripheral Vascular: Denies dizziness, palpitations, peripheral edema, history of angina, or circulation problems

            Respiratory: No cough, shortness of breath, wheezing, or sputum.

            Gastrointestinal: No nausea, loss of appetite, constipation, diarrhea, abdominal pain, bloating, or vomiting.

            Musculoskeletal: No joint pain, swelling, stiffness

Hematological: No anemia, easy bruising, and bleeding.

            Psychiatric: Denies anxiety, hallucinations, or depression.

Skin: No lesions, skin changes, or rashes.

OBJECTIVE DATA:

Physical Exam:

Vital signs: blood pressure  146/88 mmHg (left arm) and 146/90 mmHg (right arm), mean arterial blood pressure- 109 mmHg. Temperature- 36.7 degrees Celsius, heart rate-104 b/min, respiratory rate-19 breaths/min, oxygen saturation- 98% on room air.

General: A middle-aged Caucasian male, appropriate for his age and well-groomed. He is alert and oriented with no acute distress. Good oral hygiene. Well hydrated and good nutrition status. No cyanosis, jaundice, pallor, lymphadenopathy, or edema.

Cardiovascular/Peripheral Vascular: Normoactive precordium on inspection. Point of maximal impulse displaced laterally.  S1 and S2 heard. No murmurs or rubs. S3 heard at the mitral area. Right 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 digits and toes, 2 seconds.

Respiratory: Symmetrical chest that movies with respiration with no obvious chest wall deformities. Non-tender and trachea centrally located. 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: Symmetrical, round, non-distended abdomen that moves with respiration. Umbilicus inverted with no visible scars or lesions. Soft and non-tender on both light and deep palpation, the 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, power grade 5/5 across all muscle groups, normal tone, and normal reflexes. Full range of motion across all joints.

Neurological: GCS 15/15. Oriented to time, place, and person. Intact memory and speech. All cranial nerve functions are intact. Intact sensation across all dermatomes. Intact bladder and bowel function. No spinal tenderness.

Skin: dry, warm, pink, and intact. No tenting.

Diagnostic Test/Labs:

EKG- regular sinus rhythm, no ST changes. Fasting blood sugar and HbA1c to exclude diabetes given his significant family history of type 2 diabetes (Galicia-Garcia et al., 2020). He is on therapy for hyperlipidemia and therefore requires a lipid profile to evaluate the current level of control.  Additional tests include a complete metabolic panel to isolate any underlying electrolyte abnormalities, liver function tests to check liver function, and a complete blood count as a baseline for treatment.

Similarly, cardiac enzymes and brain natriuretic peptide are required to exclude myocardial infarction since chest pain can be caused by 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 since the right carotid had a bruit.

ASSESSMENT:

Priority Diagnosis

• Angina Pectoris

Differential Diagnosis

• Hypertension
• Hyperlipidemia
• Inactive lifestyle
• Myocardial infarction
• Heart Failure
• Peripheral vascular disease

Brian Foster presents with retrosternal chest pain that worsens with exertion but is relieved by rest. This is typical of angina pectoris. For an unknown reason, his chest pain does not radiate to the neck, jaw, left arm, or shoulder. According to Ferrari et al. (2019), angina pectoris is usually an indication of coronary artery disease. Coronary artery disease refers to an ischemic heart disease resulting from the narrowing of coronary vessels resulting in diminished blood flow to the myocardium.

His angina is stable since it follows exertion and is relieved by rest (Ferrari et al., 2019). According to Krittanawong et al. (2020), an estimated 90% of coronary artery disease stems from atherosclerosis. Brian Foster has risk factors for atherosclerosis including hypertension, alcohol intake, male sex, hyperlipidemia, and an inactive lifestyle (Krittanawong et al., 2020).

Brian Foster also has uncontrolled hypertension evidenced by persistently elevated blood pressure despite being on antihypertensives (Oparil et al., 2018). He also experiences occasional headaches which might be a result of elevated blood pressure. He was also diagnosed with hyperlipidemia a year ago. Hyperlipidemia refers to elevated lipid levels in the body. According to Su et al. (2021), hyperlipidemia is a risk factor for several cardiovascular disorders and therefore must be controlled. He is currently on atorvastatin and it is elemental to determine the level of control through a lipid profile. Additionally, Brian Foster has an inactive lifestyle evidenced by a lack of regular physical activity.

Brian Foster could also be having a silent myocardial infarction. Myocardial infarction is a consequence of an imbalance between myocardial oxygen demand and supply (Saleh & Ambrose, 2018). It is a common cause of retrosternal chest pain. However, the lack of ST changes on EKG points towards non-ST elevated myocardial infarction (Saleh & Ambrose, 2018). Similarly, Brian Foster has clinical manifestations of heart failure including an S3, displaced apex beat,  and bilateral crackles/rales (Schwinger, 2021). He also has hypertension and dyslipidemia which are important risk factors for heart failure. Consequently, further assessment is required to exclude this condition. Finally, he could be having a peripheral vascular disease (asymptomatic) due to diminished peripheral pulses.

References

Ferrari, R., Censi, S., & Squeri, A. (2019). Treating angina. European Heart Journal Supplements: Journal of the European Society of Cardiology, 21(Suppl G), G1–G3. https://doi.org/10.1093/eurheartj/suz190

Galicia-Garcia, U., Benito-Vicente, A., Jebari, S., Larrea-Sebal, A., Siddiqi, H., Uribe, K. B., Ostolaza, H., & Martín, C. (2020). Pathophysiology of type 2 Diabetes Mellitus. International Journal of Molecular Sciences, 21(17), 6275. https://doi.org/10.3390/ijms21176275

Krittanawong, C., Kumar, A., Wang, Z., Narasimhan, B., Mahtta, D., Jneid, H., Baber, U., Mehran, R., Tang, W., Ballantyne, C. M., & Virani, S. S. (2020). Coronary artery disease in the young in the US population-based cohort. American Journal of Cardiovascular Disease, 10(3), 189–194. https://www.ncbi.nlm.nih.gov/pubmed/32923100

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

Saleh, M., & Ambrose, J. A. (2018). Understanding myocardial infarction. F1000Research, 7, 1378. https://doi.org/10.12688/f1000research.15096.1

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

Su, L., Mittal, R., Ramgobin, D., Jain, R., & Jain, R. (2021). Current management guidelines on hyperlipidemia: The silent killer. Journal of Lipids, 2021, 9883352. https://doi.org/10.1155/2021/9883352

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
• Review the Week 7 DCE Health History Assessment Rubric, provided in the Assignment submission area, for details on completing the Assignment.
• Complete your documentation using the documentation template in your resources and submit it into your Assignment submission link below.
• From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database
• Complete the Code of Conduct Acknowledgement.

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. 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

Grading Criteria

To access your rubric:

Week 7 Assignment 1 DCE Rubric

Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS: NURS 6512 Assignment 1 Week 7: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System

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:

Click here and follow the instructions to confirm you have complied with Walden University’s Code of Conduct including the expectations for academic integrity while completing the Shadow Health Assessment.

NURS_6512_Week_7_Assignment_1_Rubric

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Name: NURS_6512_Week_7_Assignment_1_Rubric

DIGITAL CLINICAL EXPERIENCE: ASSESSING THE HEART, LUNGS, AND PERIPHERAL VASCULAR SYSTEM

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.

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?

RESOURCES

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

TO PREPARE

• Review this week’s Learning Resources and the Advanced Health Assessment and Diagnostic Reasoningmedia 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/Focused Note for Focused Exam (Required): 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 INFORMATION

• Complete your Focused Exam: Cough DCE Assignment in Shadow Health via the Shadow Health link in Canvas.
• Once you complete your assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding assignment in Canvas 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-passLinks to an external site.
• Complete your documentation using the documentation template in your resources and submit it into your Assignment submission link below.
• To submit your completed assignment, save your Assignment as WK7Assgn1+last name+first initial.
• Then, click on Start Assignmentnear the top of the page.
• Next, click on Upload Fileand select both files and then Submit Assignment for review.

Subjective Data Collection: 30 of 30 (100.0%)

Rubric

NURS_6512_Week_7_DCE_Assignment_1_Rubric