Feb 23, 2024 Assignment 1: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System NURS 6512N-32
Assignment 1: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System NURS 6512N-32
Assignment 1 Digital Clinical Experience Assessing the Heart, Lungs, and Peripheral Vascular System NURS 6512N-32
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.
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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
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
Diagnostic Test/Labs
An electrocardiogram is required as the clinical manifestations displayed lead to the patient potentially suffering from a cardiovascular condition. A chest x-ray is required to reveal any abnormalities in the chest region and in the underlying organs of the chest region that could be causing the symptoms. Lab values on CBC are also required to determine the WBC if it’s a bacterial or viral condition causing the symptoms.
Lipid profile test is also required since the patient was diagnosed with high cholesterol it would determine if the levels could be causing the symptoms. Echocardiogram could be required to determine if there could be an observable abnormality in the heart causing the symptoms. An exercise stress test is required as the patient reported symptoms are aggravated when conducting physical activity.
Pharmacology: diltiazem 30mg 6 hourly prescription is required as it would help manage his hypertension and also angina that the patient could be suffering from until the angina is controlled. Nitroglycerin when needed should also be added. The patient should also continue with previous prescriptions. Patient education: Patient should also undergo health education on diet modification and importance of a healthy diet. Referrals: patient should also consult with a vascular surgeon to see deliberate on potential interventions.
ASSESSMENT
Differential diagnosis
Coronary artery disease: this is due presence of a damage in the major blood vessels of the heart could be caused by occurrence of a plaque that narrows the vessels and limits blood flow to the heart. This is a potential diagnosis as the patient present with chest pain and the lifestyle patient has reported such as eating red meat are in line in what is found in patient with this condition (Hinkle & Cheever, 2014).
Pericarditis: this is a condition that occurs due to swelling and irritation of the structure that surrounds the heart the pericardium. It could be due to a viral infection and manifests with a sharp chest pain hence it being a potential diagnosis as the patient presents with the same (McCance & Huether, 2019).
Congestive heart failure: this is whereby the heart is unable to pump enough blood to the organs that require it. The clinical manifestations include pain in the chest area and probable weight gain hence placing it as a potential diagnosis as the patient also presented with this (Hinkle & Cheever, 2014).
Hypertension: this is a possible differential diagnosis since the patient was previously diagnosed with it whereby his blood pressure was higher than normal and if there was poor management of the condition it could lead to the clinical manifestations the patient presented with (McCance & Huether, 2019).
Hypercholesterolemia: the patient was previously diagnosed with this whereby his cholesterol levels were higher than normal hence if this condition complicated it could have led to cholesterol accumulating in the blood and limiting blood flow which could have then affected the heart and causing the symptoms the patient presented with such as chest pain (Hinkle & Cheever, 2014).
Priority diagnosis: coronary artery disease.
References
McCance, K. L., Huether, S. E., BRASHERS, V. L., & ROTE, N. S. (2019). Pathophysiology: The biologic basic for diseases in adults and children (No. ed. 8). Elsevier.
Hinkle, J. L., & Cheever, K. H. (2014). Brunner & Suddarth’s textbook of medical-surgical nursing (Edition 13.). Wolters Kluwer Health/Lippincott Williams & Wilkins.
Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation
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., a 38-year-old African American man, presented to the
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