NURS 6512 Assessment of the Heart, Lungs, and Peripheral Vascular System

NURS 6512 Assessment of the Heart, Lungs, and Peripheral Vascular System

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SUBJECTIVE DATA:

Chief Complaint (CC): “I have been having some troubling chest pain in my chest for some time now.”

History of Present Illness (HPI):  A 58-year-old Caucasian male comes to the clinic. The patient reports, “I have been having some troubling chest pain in my chest for some time now.” The patient further reports that he has been having chest pains periodically, particularly when exerting himself in the yard or while overeating. The location of the pain is at the mid sternum region, and he scores it as a 5/10 whenever he experiences it. His description of the pain is “tight and uncomfortable.” The pain does not radiate. The pain does not last for long and disappears upon the patient’s resting. His latest chest pain episode occurred three days ago at a restaurant due to a large dinner. He did not think the pain required urgent attention; however, he demonstrates concern due to the within the month, and, as such, he needs the heart to be examined. He also states that his legs cramp mildly when engaged in inactivity. He rejects the presence of dyspnea, GERD, indigestion, and heartburn. He states there is no chest pain at the time of assessment.

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.

Cardiovascular disease (CVD) is the leading cause of death worldwide. CVD, which kills 610,000 people each year (CDC, 2017), often goes undetected until it is too late. Early detection and prevention measures can save the lives of many CVD patients. One of the first steps in detecting CVD and other conditions that manifest in the thorax or chest area is a physical examination of the heart, lungs, and peripheral vascular system.

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.

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
  • Evaluate chest X-Ray and ECG imaging
NURS 6512 Assessment of the Heart, Lungs, and Peripheral Vascular System

Learning Resources

 

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

 

  • Chapter 14, “Chest and Lungs”This chapter explains the physical exam process for the chest and lungs. The authors also include descriptions of common abnormalities in the chest and lungs.

 

  • Chapter 15, “Heart”The authors of this chapter explain the structure and function of the heart. The text also describes the steps used to conduct an exam of the heart.

 

  • Chapter 16, “Blood Vessels”This chapter describes how to properly conduct a physical examination of the blood vessels. The chapter also supplies descriptions of common heart disorders.

Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.

 

  • Chapter 107, “X-Ray Interpretation: Chest (pp. 480–487) (specifically focus on pp. 480–481)

Also Read:

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

 

Note: Download the Student Checklists and Key Points to use during your practice cardiac and respiratory examination.

 

 

This study examines the medical decision making among Hispanics and non-Hispanic whites. The authors also analyze the preferred information sources used for making decisions in these populations.

 

 

 

This article describes the warning signs of impending deterioration of the respiratory system. The authors also explain the features of common respiratory conditions.

 

The authors of this article specify how to identify the major causes of acute breathlessness. Additionally, they explain how to interpret a variety of findings from respiratory investigations.

Shadow Health Support and Orientation Resources

Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

Optional Resource

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

 

  • Chapter 8, “The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts” (Section 1, “Chest Wall, Pulmonary, and Cardiovascular Systems,” pp. 302–433)Note:Section 2 of this chapter will be addressed in Week 10.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.

 

Advanced Health Assessment and Diagnostic Reasoning

Thoughtful, reasoned questioning leads from initial complaint to diagnosis in these three scenarios.
Note: Close the viewing window after the intro segment and after each diagnosis segment to view the menu. (12m)

 

Assessment of the Heart, Lungs, and Peripheral Vascular System – Week 7 (28m)

Name:

Section: Week 7 – Focused Exam: Chest Pain, Brian Foster

 

 

Week 7              

Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation

 

SUBJECTIVE DATA: 

Chief Complaint (CC): ‘’chest pain’’

 

History of Present Illness (HPI): The patient presented to the facility with a chief complaint of chest pain. The pain started within the past month and was triggered by activities such as walking up the stairs and yard work. The pain is located at the center of the chest and he characterized it as tight and uncomfortable pain. There is not burning, crushing or gnawing pain. The patient scored the pain as 5/10 on the pain severity scale. The pain is non-radiant and there is no back, shoulder, neck or arm pain. The patient reported the pain episodes last several minutes and 3 pain episodes have been experienced in the past month. However, the patient denied any relation to the pain episodes. The pain episodes are relieved by brief episodes of rest. The patient hasn’t tried any medication or other therapies to relieve the pain. The pain is aggravated by activity. There was no history of worsening pain with eating and taking spicy or high-fat food. At the time of evaluation, the patient denied any pain and the patient scored chest pain at that time as 0/10 on the pain severity scale.

 

Medications: The patient reported taking ibuprofen occasionally. The patient also takes metoprolol 100 mg once daily for his hypertension. The patient also takes fish oil supplements. Additionally, the patient takes atorvastatin 20 mg once daily at bedtime for his high cholesterol. The patient has taken atorvastatin for about a year now. However, the patient denied taking any aspirin.

Allergies: None.

 

Past Medical History (PMH): The patient reports being managed for high cholesterol and high blood pressure. The patient however, denied being managed for chest pain, coronary artery disease, angina or diabetes before. There was no history of prior hospitalizations or any risky sexual behavior. The patient was unaware of their usual blood pressure readings and reported infrequent blood pressure monitoring at home or even checkups for blood pressure. The patient reported having annual stress tests and believed the last one was normal. Additionally, the reports a history of an EKG done and the patient believes the results were normal.

Past Surgical History (PSH): There was no history of previous surgeries.

Sexual/Reproductive History: no history of children.

Personal/Social History:  The patient reports having a primary care provider and sees the provider at an interval of 6 months with the last visit being 3 months prior. The patient denied any financial or transportation barriers to accessing health care. The patient reported that their stress level was generally low. There was no history of a regular exercise routine with the last regular exercise session being 2 years prior. The patient denied any illicit drug use or tobacco smoking. The patient reported drinking alcohol weekly, especially on weekends with the patient being able to take 2 to 3 drinks at a sitting. The patient reported to be taking 2 cups of coffee daily but denied drinking soda. The patients’ diet consisted of a typical dinner of vegetables and grilled meat. The patient’s breakfast typically consisted of an instant breakfast shake and a granola bar. Moreover, the patients’ lunch typically consisted of a turkey sub. The patient reported drinking about 4 glasses of water per day and denied moderating the daily salt intake.

Immunization History: the immunization status is up to date including the tetanus vaccine.

Significant Family History: There was a family history of heart attacksThere was no family history of pulmonary embolism or stroke.

Review of Systems: 

General: no history of weight loss, no fatigue, no fever, no dizziness or lightheadedness, no chills, no night sweats.

HEENT: no difficulty in swallowing, no change in sense of taste, no sore throat.

Cardiovascular/Peripheral Vascular: No palpitations, no cyanosis, no easy bleeding, no history of blood clots, no history of angina, no history of circulatory problems, no oedema, no history of murmurs, no history of rheumatic fever, no easy bruising.

Respiratory: no shortness of breath at rest, no difficulty in breathing, no orthopnea, no cough.

Gastrointestinal: no bloating, no nausea, no diarrhea, no gassiness, no heartburn or GERD, no constipation, no vomiting.

Musculoskeletal: no stiffness, no joint pain

Psychiatric: no history of anxiety, no depression, no psychiatric admissions.

 

OBJECTIVE DATA:

Physical Exam:

Vital signs: Temperature 97.5 F, BP 118/79mmHg, Pulse 79b/min, oxygen saturation 97%, respiratory rate 17, height 5”2”, weight 177 Ibs,

General: no pallor, no cyanosis, no finger clubbing, no oedema, no splinter hemorrhages, scars, no redness or flushing, no varicose veins,

Cardiovascular/Peripheral Vascular: capillary refill less than 3 seconds, jugular venous distention less than or equal to 4 cm above sternal angle, a thrill palpated in the right carotid artery, no thrill in the left, increased amplitude of right carotid artery at 3+, the amplitude of left carotid at expected (2+), PMI displaced laterally with a diameter less than 3 cm and brisk and tapping amplitude, no thrills in brachial arteries with expected amplitude, no thrills in radial arteries with expected amplitude, no thrills in femoral arteries with expected amplitude, no thrills in popliteal arteries with diminished or barely palpable amplitude, no thrills in tibial arteries with diminished or barely palpable amplitude, no thrills in dorsalis pedis arteries with diminished or barely palpable amplitude, bruit in the right carotid artery, no bruit in the left, S1, S2 and S3 heard, gallops heard

Respiratory: symmetrical appearance, no rashes, no lesions, no intercostal retractions, breath sounds heard bilaterally, no added sounds,

Gastrointestinal: symmetrical appearance, no striae, no scars, no bruising, no distention, abdomen tympanic in all areas, no tenderness, no masses, no guarding, no rigidity, liver palpable with a span between 6 to 12 cm, no friction rub, no tenting, normoactive bowel sounds, no bruits,

Musculoskeletal: not joint pain, no stiffness.

Neurological: No dizziness, no focal deficits.

Skin: no ulceration, no thickening, no brownish pigmentation, no rashes, no moles or skin tags, no purpura, no dryness, no lacerations,

Diagnostic Test/Labs: EKG done- regular sinus rhythm, no ST elevation

ASSESSMENT:

Primary Diagnosis: Angina

Stable angina may present with recurrent chest pain worsened on exertion and relieved by rest (Joshi & de Lemos, 2021). Drugs such as nitroglycerine may also alleviate the pain due to angina. The pain may also radiate to the jaw, neck, shoulder or arms. The pain of stable angina may be frequent and may develop a pattern in terms of frequency, severity and triggers. Atherosclerosis can be a secondary cause. Patients may however have normal physical exam findings. A third heart sound is also common in angina (Jameson, 2018). The patient in question presented with recurrent, central, non-radiating chest pain that lasted several minutes, relieved on rest, triggered by exertion such as performing yard ward and walking the stairs. The patient had also experienced 3 pain attacks within the past month. The physical findings especially cardiovascular exam could point to atherosclerosis as revealed by the thrill in the right carotid artery, bruit in the right carotid artery and inequality in the pulse amplitudes of the right and left carotids. Some of the other physical findings were within normal ranges. The PMI was also displaced laterally. The pain of unstable angina is severe and may occur without triggers (Reed et al., 2018). It may also not be relieved by rest. Displacement of the PMI could indicate cardiomegaly (Vinay Kumar, 2017). The patient thus presents with symptoms likely to be due to stable angina.

Differential Diagnosis:

  1. Myocardial Infarction

Myocardial infarction may also present with chest pain. The pain may radiate to the jaw, neck, arm or back. The pain may be described as ‘squeezing’ or ‘choking’ pain and is severe (Saleh & Ambrose, 2018). The pain is not relieved by rest and this is a key difference with stable angina. The pain also occurs for a longer duration compared to that of angina. Atherosclerosis is known as a risk factor and given the cardiovascular examination findings; the patient may be at risk of myocardial infarction (Hall & Hall, 2020). A third heart sound may be heard and EKG results may reveal either ST-segment elevation or depression. The patient in question presented with central chest pain that was relieved by rest. The examination findings also revealed S3. This is a likely diagnosis.

  1. Aortic stenosis 

The presentation may include chest pain than worsens on physical activity. It may also present as syncope, fatigue, convulsions and back pain. there may be a decreased amplitude of the carotid arteries on examination of these patients. Patients may also present with S4 and systolic murmurs (Santangelo et al., 2021). The patient presented with chest pain that worsened physical activity. This is also a likely diagnosis.

  1. Myocarditis

This inflammatory condition may result in chest pain, fatigue, syncope, palpitations, shortness of breath and constitutional symptoms such as fever, chills and sweats. It may also present with a gallop rhythm, tachycardia and oedema (Lampejo et al., 2021). The pain may be constant and even present during periods of rest. Chronic myocarditis may present with recurrent symptoms. It may result from infectious causes such as viruses. The EKG findings may include ST segment depression. The patient presented with a gallop rhythm and chest pain. The patient however did not present with EKG changes. This remains a likely diagnosis

 

References

Hall, J. E., & Hall, M. E. (2020). Guyton and Hall textbook f medical physiology. (14th ed.). Elsevier – Health Science.

Jameson, J. L. (2018). Harrison’s principles of internal medicine (20th ed.). New York Mcgraw-Hill Education.

Joshi, P. H., & de Lemos, J. A. (2021). Diagnosis and Management of Stable Angina: A Review. JAMA, 325(17), 1765–1778.

Lampejo, T., Durkin, S. M., Bhatt, N., & Guttmann, O. (2021). Acute myocarditis: aetiology, diagnosis and management. Clinical Medicine, 21(5), e505–e510.

Reed, S. M., Bayly, W. M., & Sellon, D. C. (2018). Equine internal medicine. Elsevier.

Saleh, M., & Ambrose, J. A. (2018). Understanding myocardial infarction. F1000Research, 7(1), 1378.

Santangelo, G., Rossi, A., Toriello, F., Badano, L. P., Messika Zeitoun, D., & Faggiano, P. (2021). Diagnosis and Management of Aortic Valve Stenosis: The Role of Non-Invasive Imaging. Journal of Clinical Medicine, 10(16), 3745.

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:
General: Head: EENT: etc.

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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