NURS 6512 Digital Clinical Experience Assessing the Heart, Lungs, and Peripheral Vascular System
Initials: M.H Age: 60 years Old Sex: Male Race: Caucasian
CC: “I am having shortness of breath; it’s been getting worse. I just feel tired all the time.”
HPI: M.H is a 60 years old Caucasian male patient who came to the hospital complaining of shortness of breath which has been worsening over time.
Associated signs and symptoms:
Exacerbating/ relieving factors:
Soc Hx: The patient has been smoking in the past with no success in quitting. Currently, he confirms smoking three cigarettes a day.
GENERAL: proper posture. No weight loss or weight gain, chills, fever, nausea or vomiting.
HEENT: Eyes: denies visual loss, double vision, blurred vision, or using a visual aid. Ears, Nose, Throat: denies hearing difficulties, sneezing, sore throat or running nose.
SKIN: No rash, mole or itching.
CARDIOVASCULAR: confirms chest pressure and chest discomfort. Irregular heart rate with S1 and S2 sounds and no S3 or S4 sounds. No murmurs.
RESPIRATORY: confirms shortness of breath. Denies congestion or wheezing. Denies being exposed to an infected individual with a contagious respiratory infection in the past.
GASTROINTESTINAL: Denies anorexia, diarrhea, nausea or vomiting. Confirms a slight protuberant of the abdomen.
GENITOURINARY: denies burning on urination, foul urine odor or strange urine color. Confirms normal urine frequency.
NEUROLOGICAL: Denies headache, syncope, dizziness, paralysis, numbness, ataxia, or tingling in the extremities.
MUSCULOSKELETAL: Denies muscle pain. Confirms pain associated with joint movement of the lower extremities.
LYMPHATICS: Confirms edema on the right calf.
PSYCHIATRIC: Denies any history of anxiety or depression.
Physical exam: Physical exam: Vital signs: B/P 148/88, HR 112bpm (Fast and irregular); T 97.9F orally; RR 32; labored; SpO2: 90% room air; Wt.: 210lbs; Hit: 5’7
General: Well oriented and cooperative. Slightly anxious but able to respond appropriately to the questions asked. Seems to have slight respiratory distress.
HEENT: head: atraumatic and normocephalic. Eyes: bilateral with no visual aid. The pupils are round, equal and bilaterally reactive to light. Ears: normal bilateral hearing.
Skin: Cool and diaphoretic. No cervical lymphadenopathy. No rashes
Chest/Lungs: Thorax symmetrical; diminished breath sounds right middle and lower lobes; no rales, rhonchi, or wheezes; breath sounds vesicular with no adventitious sounds on the left lung.
Heart/Peripheral Vascular: Heart rate is irregular with good S1, S2; no S3 or S4; no murmur. Right calf with 2+ edema, erythema; warmth and tenderness on palpation noted; left lower extremity without edema or erythema; 2+ dorsalis pedis pulses bilaterally
Abdomen: Bulgy with normoactive bowel sounds auscultated x4 quadrants
Genital/Rectal: The bladder is continent. No rashes around the genitalia.
Musculoskeletal: moderate pain of 5/10 on the RLE calf. Right calf with 2+ edema. Motion is of the normal range. There are no deformities of the joints.
Neuro: Alert and well oriented. Normal body posture. Slightly lethargic but with intact sensation.
Diagnostic results: Evaluation of the patient’s health complication require incorporation of the patient history, physical examination and lab test results. Based on the provided information, further diagnosis can be made with regard to the results of several lab tests. A complete blood count is necessary for ruling out infections or anemia as the root cause of the patient’s symptoms. Urinalysis is required in evaluating proteinuria in association with cardiovascular disease. CMP to check for renal dysfunction or fluid retention. An elevated level of fasting glucose also indicates high risks of heart failure (Papadakis, McPhee, & Bernstein, 2019). Natriuretic peptides should also be tested as they increase significantly in cases associated with heart failure. Lipid profile tests and TSH are relevant in assessing thyroid diseases in relation to heart failure. EKG will reveal arrhythmias, coronary artery disease, myocardial infarction and ischemia as possible causes of cardiac failure. Chest X-ray may reveal pulmonary congestion, hypertrophied cardiac silhouette among other causes of the patient’s symptoms.
- Congestive Heart Failure: This condition is characterized by the buildup of fluids in the feet, legs, ankle, liver, abdomen and veins on the neck region, in addition to fatigue and shortness of breath (Shahbazi, & Asl, 2015). The patient displays symptoms of shortness of breath, and fatigue. Upon physical examination, it was revealed that the patient’s lower extremities were swollen, abdomen distended, irregular heart rate slightly elevated blood pressure, oxygen concentration and respiratory rate. All these symptoms point towards CHF as the primary diagnosis of the patient presenting illness.
- Myocardial Infarction: This condition is characterised by fatigue, malaise, chest discomfort, shortness of breath, rapid and irregular heartbeat and cough. Upon physical examination, patients with MI, usually exhibit an increased and irregular heart rate, elevated blood pressure, increased respiratory rate, fever, rales or wheezes may be auscultated, and edematous extremities (Reddy, Khaliq, & Henning, 2015). The patient was positive for most of these sign and symptoms.
- Pulmonary Embolism: The main indication for pulmonary embolism is a sudden onset of pleuritic chest pain, hypoxia and shortness of breath. Some patients may, however, lack the apparent symptoms, and instead present with an abrupt, catastrophic hemodynamic collapse or gradually progressive dyspnea (Kan et al., 2015). Due to the variation of the symptoms, pulmonary embolism is usually suspected in individuals with respiratory symptoms which are unexplainable by an alternative diagnosis, just like in the above case scenario.
- Pneumonia: Patients with pneumonia usually display symptoms such as fever, dyspnea, pleuritic chest pain, fatigue and cough. Upon physical examination, some of the findings will include tachypnea, bronchial breath sounds, rales noted over the affected lobe, decreased tactile fremitus and dullness on percussion of the chest (Papadakis, McPhee, & Bernstein, 2019). Some of these sign and symptoms were exhibited by M.H making pneumonia a potential differential diagnosis.
- Pericardial effusion: This condition usually presents as a result of inflammation of the pericardium following an injury or illness. It is characterized by chest congestion, dyspnea, fatigue, orthopnea, cough and lightheadedness. The patient was positive for most of these symptoms (Papadakis, McPhee, & Bernstein, 2019). Consequently, the physical examination findings of an individual with pericardial effusion include decreased breathing sounds, Ewart sign, tachypnea, tachycardia, pericardial friction rub, pulses paradoxus and hepatojugular reflux.
Shahbazi, F., & Asl, B. M. (November 01, 2015). Generalised discriminant analysis for congestive heart failure risk assessment based on long-term heart rate variability. Computer Methods and Programs in Biomedicine, 122, 2, 191-198.
Reddy, K., Khaliq, A., & Henning, R. J. (January 01, 2015). Recent advances in the diagnosis and treatment of acute myocardial infarction. World Journal of Cardiology, 7, 5, 243-276.
Kan, Y., Yuan, L., Meeks, J. K., Li, C., Liu, W., & Yang, J. (May 01, 2015). The accuracy of V/Q SPECT in the diagnosis of pulmonary embolism: a meta-analysis. Acta Radiologica, 56, 5, 565-572.
In Papadakis, M. A., In McPhee, S. J., & In Bernstein, J. (2019). Quick medical diagnosis & treatment 2019. New York, N.Y.: McGraw-Hill Education LLC.
You are admitting a 19-year old female college student to the hospital for fevers. Using the patient information provided, choose a culture unfamiliar to you and describe what would be important to remember while you interview this patient. Discuss the health care support systems available in your community for someone of this culture. If no support systems are available in your community, identify a national resource.
Child Developmental Assessment
College Name, Grand Canyon University
Course Number: NRS-434VN
Topic 4 DQ 1
Dr. Lily Polsky
16 February 2022.
Culture is defined as the way of life of a people. It is also seen as the customs, arts, social institutions, and achievements of a particular nation, people, or other social group. It is important for nurses to consider the cultural beliefs of their patients while rendering care. The cultural needs of patients should be determined immediately the walk through the door. The nurse should be very observant to check if the patient makes eye contact and communicate well during the interview. It is essential we build a trusting relationship with the patient throughout their hospital stay. The nurse should exercise cultural competency which involves the respect of all beliefs, values, and decision-making power of the patient within a different group cultural group than the nurse.
The Arab American culture
The Arab American has a unique culture, and the nurse should remember that when first treating a patient, they should refrain from any excess eye and physical contact (Attum, Haffiz, Malik, 2020). Maintaining privacy is essential and modesty is important. The family should be included in the treatment planning. This female needs to be seen by female health care providers. It is required in this culture that the patient be assessed by medical professional that are of the same gender as the patient (Falkner, 2018). Respecting the cultural diet is paramount. It is the nurses` responsibility to make the patient feel safe and respected (Falkner, 2018).
Health care support system
The language telephone line should be used for patient during the interview if she feels more comfortable using her preferred language. The language line at the facility where I work has just has video option that the nurse can utilize if the patient gives the consent. Spiritual care should be provided. This because prayer and religion are valued among the Arab Americans (Attum, Haffiz, Malik, 2020). The support system is Arab American Family Services which offer support in the areas of public benefits, immigration, domestic violence, mental health, elderly services, and they sponsor outreach programs to build healthier families and communities (AAFS, 2020)
Arab American Family Services (2020). Support for Arab American Families: About Us. Retrieved from http://arabamericanfamilyservices.org/about-us/
Attum, B., Hafiz, S., Malik, A. (2020). Cultural Competence in the Care of Muslim Patients and Their Families. Retrieved from: htts://www.ncbi.nlm.gov/books/NBK499933/
Falkner, A. (2018). Cultural awareness. In Grand Canyon University Ed.). Health promotion: Health & wellness across the continuum. Retrieved from https://lc.gcumedia.com/nrs429vn/health-promotion-health-and-wellness-across-the-continuum/v1.1/#/chapter/3