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?

• 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)
• Chapter 107, “X-Ray Interpretation: Chest (pp. 480–487)
• Download “X-Ray Interpretation: Chest (pp. 480–487)
• 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.
• Chapter 8, “Chest Pain”
• Download Chapter 8, “Chest Pain”
  This chapter focuses on diagnosing the cause of chest pain and highlights the importance of first determining whether the patient is in a life-threatening condition. It includes questions that can help pinpoint the type and severity of pain and then describes how to perform a physical examination. Finally, the authors outline potential laboratory and diagnostic studies.
• Chapter 11, “Cough”
• Download Chapter 11, “Cough”
  A cough is a very common symptom in patients and usually indicates a minor health problem. This chapter focuses on how to determine the cause of the cough by asking questions and performing a physical exam.
• Chapter 14, “Dyspnea”
• Download Chapter 14, “Dyspnea”
  The focus of this chapter is dyspnea, or shortness of breath. The chapter includes strategies for determining the cause of the problem through evaluation of the patient’s history, through physical examination, and through additional laboratory and diagnostic tests.
• Chapter 26, “Palpitations”
• Download Chapter 26, “Palpitations”
  This chapter describes the different causes of heart palpitations and details how the specific cause in a patient can be determined.
• Chapter 33, “Syncope”

• Download Chapter 33, “Syncope”
  This chapter focuses on syncope, or loss of consciousness. The authors describe the difficulty of ascertaining the cause, because the patient is usually seen after the loss of consciousness has happened. The chapter includes information on potential causes and the symptoms of each.

• Links to an external site. https://link.shadowhealth.com/Student-Orientation-Video
• Shadow Health. (n.d.). Shadow Health help desk.
• Links to an external site.Retrieved from https://support.shadowhealth.com/hc/en-us
• Shadow Health. (2021). Walden University quick start guide: NURS 6512 NP students

Download Walden University quick start guide: NURS 6512 NP students.

• Links to an external site. https://link.shadowhealth.com/Walden-NURS-6512-Student-Guide
• Document: DCE (Shadow Health) Documentation Template for Focused Exam: Chest Pain (Word document)

Download DCE (Shadow Health) Documentation Template for Focused Exam: Chest Pain (Word document)
Use this template to complete your Assignment 1 for this week.

Expert Answer and Explanation

Focused SOAP Note

SUBJECTIVE DATA: 

Chief Complaint: “I have chest pain that has lasted about a month.”

History of Present Illness (HPI): Brian Foster is a 58-year-old male of Caucasian origin who presents to the clinic complaining of chest pain that has lasted about a month. The patient says that the pains make his chest feel tight, non-radiating, and uncomfortable. On a scale of 1-10, the patient rates the pain as five out of ten.

The says that his last episode of chest pain and tightness started three days ago. The first episode occurred when he was at work, the send while down the stairs to bed, and the third while having dinner with his wife. The says that the pain is aggravated when he moves and relieved when he is resting. The pain has never been worse and has not thought of it as an emergency. However, he was concerned when the pain occurred thrice in one month and that is why he came for a heart check-up. Other associated symptoms include pain in the jaws, fatigue, shortness of breath when episodes occur, and dizziness.

Medications: Atorvastatin (Lipitor) 20 mg PO Daily at bedtime, last dose 10 pm yesterday, Metoprolol (Lopressor) 100mg PO daily, Omega-3 Fish Oil 1200 mg PO BID last dose 8 am (OTC supplement), Lisinopril (Prinivil) 20mg PO daily, OTC Ibuprofen for pain management, OTC Tylenol for pain.

Allergies: He is allergic to Codeine. He experiences vomiting and nausea after taking Codeine.

Past Medical History (PMH): He was diagnosed with Hyperlipidemia and Hypertension- Stage II one year ago.

Past Surgical History (PSH): NO history of surgery.

Sexual/Reproductive History: Not Applicable.

Personal/Social History: Drinks 2 -3 beers on Sundays. Denies smoking or use of illicit drugs. He has two children aged 19 and 26. Exercised last two years ago but is conscious about his diet.

Immunization History: Received Influenza vaccine this season and Tdap on 2014 October.

Significant Family History: Father had obesity, HBP, and hyperlipidemia. He died at age 75 of colon cancer. The mother and sister have hypertension and type two diabetes. His maternal grandfather died at age 54 from a heart attack. His Maternal grandmother died at age 65 from breast cancer. His Paternal grandmother died at age 78 from pneumonia and his paternal grandfather died at age 85 of old age. His daughter is asthmatic at age 19.

Review of Systems 

• General: No weight loss, fever. Reports weakness.
• Cardiovascular/Peripheral Vascular:Denies previous heat problems.
• Respiratory: Denies previous respiratory issues. No cough.
• Gastrointestinal:No adnominal pain.
• Musculoskeletal:No joint or muscle pain.
• Psychiatric:No mental health diseases. Denies depression or anxiety.

OBJECTIVE DATA:

Physical Exam:

• Vital signs:P 104, BP 146/90, RR 19, Temp 36.4, SPO2: 98% in room air, Wt. 197lbs, Ht. 5’ 11.
• General: The patient is alert and oriented to place, time, and people. He is well-dressed and answers questions appropriately. His speech is clear. He sits comfortably with no acute distress. He walks without crutches and his gait is normal. His mood is normal and his affect is consistent with his mood. His concertation is normal.
• Cardiovascular/Peripheral Vascular: S1 and S2 without rubs or murmurs. No fluid retention or swelling of the chest. S3 is present in the mitral region. LJP is present 3 cm above the sternal angle. No JVD present. Right carotid pulse with thrill, 3+. Tight side carotid with bruit. Left carotid with no bruit. Capillary refill is <3 seconds in all 4 extremities.
• Respiratory: Fine crackles present in posterior bases of L/R lungs. Breathing in unlabored and quiet. No wheezes or gallops.
• Gastrointestinal:Normal bowel movements in all four quadrants. The abdomen is non-tender and soft. No abdominal pain. No tenderness to deep or light palpation. Tympanic throughout. No abdominal bruits.
• Musculoskeletal:No joint or muscle pain or swelling.
• Neurological:Moves all extremities. He is oriented and alert.
• Skin:No rash or burning.

Diagnostic Test/Labs: 

• Electrocardiogram: EKG is needed to check the patient’s heart rate.
• Chest-X-ray: A chest x-ray will show the condition of the lungs and chest. The test can help determine the cause of the symptoms presented by the patient.
• Blood tests: Blood tests can show if heart enzymes have entered the bloodstream.

ASSESSMENT:

Differential Diagnosis

1. Angina Pectoris
2. Congestive heart failure
3. Carotid artery disease

The primary diagnosis for this case is angina pectoris. According to Gallone et al. (2021), angina pectoris causes chest tightness and pain. The authors also note that the disease causes shortness of breath and fatigue. All these symptoms are present in the patient. The patient also has hypertension which is a risk factor for the disease (Webb & Collins, 2021).

Chest pain in angina is increased during activity and relieved on rest as experienced by the patient. The second diagnosis is congestive heart failure. The disease is part of the diagnosis because it causes shortness of breath, fatigue and chest pain (Seah et al., 2019). The presence of S3 in the mitral region is a vital sign of congestive heart failure.

However, it is a secondary diagnosis because there is no presence of severe narrowing of blood vessels (Porumb et al., 2020). The last diagnosis is carotid artery disease. The disease causes chest pain and that is why it has been included in the diagnosis (Kashyap et al., 2020). However, it is a secondary diagnosis because it causes trouble speaking and numbness and tingling of limbs which are not present in this case.

References

Gallone, G., Baldetti, L., Angelini, F., Saglietto, A., Bellettini, M., Beneduce, A., & De Ferrari, G. M. (2021). The placebo effect on symptoms, quality of life, and functional outcomes in patients with angina pectoris: A meta-analysis of randomized placebo-controlled trials. Canadian Journal of Cardiology. https://www.sciencedirect.com/science/article/pii/S0828282X21002415

Kashyap, V. S., Schneider, P. A., Foteh, M., Motaganahalli, R., Shah, R., Eckstein, H. H., & ROADSTER 2 Investigators*. (2020). Early outcomes in the ROADSTER 2 study of transcarotid artery revascularization in patients with significant carotid artery disease. Stroke, 51(9), 2620-2629. https://doi.org/10.1161/STROKEAHA.120.030550

Porumb, M., Iadanza, E., Massaro, S., & Pecchia, L. (2020). A convolutional neural network approach to detect congestive heart failure. Biomedical Signal Processing and Control, 55, 101597. https://doi.org/10.1016/j.bspc.2019.101597

Seah, J. C., Tang, J. S., Kitchen, A., Gaillard, F., & Dixon, A. F. (2019). Chest radiographs in congestive heart failure: Visualizing neural network learning. Radiology, 290(2), 514-522. https://doi.org/10.1148/radiol.2018180887

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. https://doi.org/10.1016/j.ijcard.2021.07.018

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