NURS 6512 DIGITAL CLINICAL EXPERIENCE: ASSESSING THE HEART, LUNGS, AND PERIPHERAL VASCULAR SYSTEM

Walden University NURS 6512 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 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.

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Whether one passes or fails an academic assignment such as the Walden University NURS 6512 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 DIGITAL CLINICAL EXPERIENCE: ASSESSING THE HEART, LUNGS, AND PERIPHERAL VASCULAR SYSTEM

The introduction for the Walden University NURS 6512 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.

How to Write the Body for NURS 6512 DIGITAL CLINICAL EXPERIENCE: ASSESSING THE HEART, LUNGS, AND PERIPHERAL VASCULAR SYSTEM

After the introduction, move into the main part of the NURS 6512 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 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 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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Sample Answer for NURS 6512 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): “In the last month, I have occasionally had some unsettling chest
discomfort.”
History of Present Illness (HPI): A 58-year-old Caucasian man named B.F. visits the clinic and
complains of occasional, painful chest pain that has occurred three times in the previous month
but has merely lasted a few minutes on each occasion. The client realized it may have been
heartburn after a short while. He rates his present degree of discomfort as a 0/10, and at his
worst, a 5/10. He says his chest is tight and unpleasant in the center, but he says the discomfort
isn’t radiating. The patient asserts that pain relief occurs when he is resting motionless and is
worse when he is engaging in physical activity, such as raking leaves or climbing stairs.
Additionally, he described experiencing chest pain after eating too much.

1. Location-The center of the chest.
2. Quality-Tight and unpleasant
3. Quantity or severity-0/10 at the present, 5/10 at its worst.
4. Timing, including onset, duration, and frequency-started a month ago, lasted a few
   minutes, and happened three times.
5. Setting in which it occurs- Occurs when going to work and while doing yard chores
   at home.
6. Factors that have aggravated or relieved the symptom:Pain is lessened by lying
   down and increased by exercise.
7. Associated manifestations-slight leg cramps when moving around
   Medications:
    Atorvastatin (Lipitor) 20 mg once a day
    Lisinopril (Prinivil) 20 mg once daily
    Omega-3 Fish Oil, 1200 mg twice daily taken orally.
    As required, Tylenol and Ibuprofen.
   Allergies: Codeine – makes him feel sick to his stomach. Denies sensitivities to certain foods or
   environments.
   Past Medical History (PMH):
    Stage II hypertension and hyperlipidemia
    Colonoscopy at 50 years old
8. Past Surgical History (PSH): neither a recent hospitalization nor a surgical history.
9. Sexual/Reproductive History: For the past 27 years, he has only had one sexual relationship
10. while married.
11. Personal/Social History: The patient works as an engineer. He has been married for 27 years.
12. The patient has two children, a daughter, 19, and a son, 26. He says he has a primary care doctor,
13. although three months had passed since the last visit. The client denies taking any illicit drugs,
14. including cigarettes, cannabis, heroin, cocaine, or any combination thereof. During weekends,
15. consumes two to three beers. He used to routinely ride his bike, but not anymore. The doctor
16. gave him the go-ahead, and he intends to start exercising. Together with his youngerbrother and
17. a friend, the patient likes to go fishing. The client consumes occasional fried meals but mostly
18. stays healthy.
19. Immunization History:
20.  2014 October Tdap.
21.  Current with flu shots.
22.  Denies immunization for pneumonia.
23. Significant Family History:
24.  Father: Obese, with high blood pressure and hyperlipidemia, deceased at age 75 from
25. colon cancer.
26.  Mother, 65, suffers from type 2 DM and HTN.
27.  Sister, 52, suffers from type 2 DM and HTN.
28.  Brother: Died many years ago in a car accident at the age of 24.
29.  The daughter, age 19, is asthmatic, and hypertensive.
30.  Son: 26-year-old, healthy.
31.  Maternal grandmother: 65 years old; died of breast cancer.
32.  Maternal grandfather: died at age 54 from a heart attack.
33.  Paternal grandmother’s death was caused by pneumonia; she was 78 years old.
34.  The paternal grandfather’s death was attributed to “old age.” Age 85.
35. Review of Systems:
36. General: The patient is not experiencing sweating or chills. Weight gain of 20
37. pounds during the last few years. Denial of exhaustion or stress, no changes in
38. appetite.
39. HEENT: Normocephalic head with no scars. Eyes: The patient is without
40. spectacles. No reported difficulties with the ears. No abnormality was noted in the
41. nose. Throat: Nothing unusual has been noted.
42. Cardiovascular/Peripheral Vascular: Disavows the presence of edema in the
43. lower limbs on either side as well as a rapid, irregular, or fast heartbeat. disavows
44. orthopnea. reports of middle-chest discomfort that does not go to the arm, neck,
45. shoulder, or back.

Respiratory: The client has dyspnea while under stress (from exercise and
climbing stairs at work). No cough.
Gastrointestinal: Disavows experiencing stomach discomfort, diarrhea,
constipation, or any changes to bowel or bladder habits. No stomach ache or
blood in the stools. denies having diarrhea and motion sickness.
Musculoskeletal: No back, joint, or muscular discomfort. Balance and gait
remain unchanged.
Integumentary: No abnormalities have been noted
Neurological: Disavows tension headaches or injury.
Psychiatric: Denies anxiety, sadness, and mood swings.

OBJECTIVE DATA:

Physical Exam:
Vital signs:T. 36.7, P 109, B/P 146/90, RR 19, O2 98% on room air; Wt. 197lbs; H 5’11”
General: The client is awake and focused. The client is friendly and suitably attired. No
changes in attitude or conduct; appearance is tidy and hygienic.
Cardiovascular/Peripheral Vascular: No JVD. No obvious abnormalities
were apparent in the chest. No edema in the either lower extremity. No thrill in the left
carotid artery, 2+ amplitude. bruit, thrill, and 3+ amplitude in the right carotid artery.
Noted cardiac sounds: S1, S2, and S3. Gallop is there. PMI smaller than 3 cm in
diameter, displaced laterally, brisk, and tapping. Less than three upper and lower bilateral
extremities receive capillary refilling. Radial and brachial pulses on either side: +2.
diminished +1 popliteal, tibial, and pedal pulses bilaterally. conducted EKG; NSR
showed no ST elevation.
Respiratory: Sounds from respiration are audible. Fine crackles in the lower posterior
lobes on both sides.
Gastrointestinal: Round, symmetrical, and without any obvious pathological
abnormalities in the abdomen. Bowel noises are present and vigorous in each quadrant as
usual. No visible bulk, although there is soreness. The kidney and spleen are not palpable.
1 cm below the right costal border, palpable liver. No rubbing is felt. Everywhere is
tympanic. Middle of the clavicular line: 7 cm of the liver.
Musculoskeletal: The strength of the bilateral upper and lower limbs is equal, and the
gait is steady and unassisted.
Skin: Warm, dry, and unblemished. It is OK to have skin turgor without tenting. Non-
brittle and neat nails. No open skin or scars were seen. Unnoticed lesions.

Diagnostic Test/Labs: The results of the EKG revealed a normal sinus rhythm with no ST
elevation. CCTA, Echo, CXR, Cardiac enzymes, BNP, CBC, CK, troponins, stress test, and
other testswere ordered.

ASSESSMENT:

1. Stable Angina: Angina is a chronic chest discomfort that is brought on by stress, tension,
   or physical effort and that goes away with rest or nitroglycerin medicine(Loscalzo, 2022).
   The back of the neck, the chin, left the arm, or the epigastric area may also experience
   this squeezing or tightening ache, which is difficult to pinpoint. Other ischemia
   symptoms that may be anginal equivalents include dyspnea and dyspepsia. Angina might
   become better with time or remain the same (Caselli et al., 2021). Particularly when
   angina is more frequent, unprovoked, severe, or persistent, symptom progression calls for
   attention. The acute coronary syndrome should be taken into consideration and rapidly
   evaluated if severe rest symptoms are observed. It is advised for a patient to have a
   diagnostic CCTA examination (Ferraro et al., 2020). The patient’s symptoms and risk
   factors are confirmed by the differential diagnosis of stable angina.
2. Congested Heart Failure/Ventricular Dysfunction: Ventricular dysfunction is a
   condition that results in heart failure (HF). Shortness of breath and weariness are
   symptoms of left ventricular (LV) failure, while peripheral and abdominal fluid buildup
   is a symptom of right ventricular (RV) failure (Bernhard et al., 2023). The first clinical
   diagnosis is backed by chest x-ray, electrocardiograms, and plasma natriuretic peptide
   levels. Patients with heart failure (HF), whether overt or subclinical, benefit from having
   evidence of S3 as a crucial prognostic indication. Along with other antihypertensives,
   treatment involves educating the patient and using diuretics, ACE inhibitors, and
   angiotensin II channel blockers, among other antihypertensives (Li et al., 2019).
3. Carotid Artery Disease: Conducting a thorough physical and medical evaluation is
   essential before going on to the next stage of treatment. Two probable consequences of
   coronary artery disease include stable ischemic heart disease and acute coronary
   syndrome (Manchanda et al., 2022). It can result in congestive heart failure (CHF) if left
   untreated. People who have chest pain should be questioned about its source, degree, and
   whether or not it spreads to other areas of their body. It’s critical to evaluate dyspnea
   throughout rest and during physical activity (Bonati et al., 2022). Additionally, questions
   regarding syncope, palpitations, tachycardias, tachypnea, lower-extremity edema,
   orthopnea, and exercise tolerance should be asked. A person’s dietary, tobacco use, and
   lifestyle habits must be investigated, as ought any ischemic heart disease in the family
   history.

References

Bernhard, B., Schnyder, A., Garachemani, D., Fischer, K., Tanner, G., Safarkhanlo, Y., Stark, A.
W., Schütze, J., Pavlicek-Bahlo, M., Greulich, S., Johner, C., Wahl, A., Benz, D. C.,
Kwong, R. Y., & Gräni, C. (2023). Prognostic Value of Right Ventricular Function in
Patients With Suspected Myocarditis Undergoing Cardiac Magnetic Resonance. JACC:
Cardiovascular Imaging, 16(1), 28–41. https://doi.org/10.1016/j.jcmg.2022.08.011
Bonati, L. H., Jansen, O., de Borst, G. J., & Brown, M. M. (2022). Management of
atherosclerotic extracranial carotid artery stenosis. The Lancet Neurology, 21(3),
273–283. https://doi.org/10.1016/s1474-4422(21)00359-8
Caselli, C., De Caterina, R., Smit, J. M., Campolo, J., El Mahdiui, M., Ragusa, R., Clemente, A.,
Sampietro, T., Clerico, A., Liga, R., Pelosi, G., Rocchiccioli, S., Parodi, O., Scholte, A.,
Knuuti, J., & Neglia, D. (2021). Triglycerides and low HDL cholesterol predict coronary
heart disease risk in patients with stable angina. Scientific Reports, 11(1).
https://doi.org/10.1038/s41598-021-00020-3
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, A. (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
Li, B., Ming, Z., Wu, J., & Zhang, M. (2019). Nonobstructive coronary artery myocardial
infarction is complicated by heart failure, ventricular aneurysm, and incessant ventricular
arrhythmia. Medicine, 98(2), e13995. https://doi.org/10.1097/md.0000000000013995
Loscalzo, J. (2022). Evaluating Stable Chest Pain — An Evolving Approach. New England
Journal of Medicine, 386(17), 1659–1660. https://doi.org/10.1056/nejme2201446
Manchanda, A. S., Kwan, A. C., Ishimori, M., Thomson, L. E. J., Li, D., Berman, D. S., Bairey
Merz, C. N., Jefferies, C., & Wei, J. (2022). Coronary Microvascular Dysfunction in
Patients With Systemic Lupus Erythematosus and Chest Pain. Frontiers in
Cardiovascular Medicine, 9. https://doi.org/10.3389/fcvm.2022.867155

Also Read:

ASSESSING MUSCULOSKELETAL PAIN

CASE STUDY ASSIGNMENT: ASSESSING NEUROLOGICAL SYMPTOMS

DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT

LAB ASSIGNMENT: ASSESSING THE GENITALIA AND RECTUM

Sample Answer 2 for NURS 6512 DIGITAL CLINICAL EXPERIENCE: ASSESSING THE HEART, LUNGS, AND PERIPHERAL VASCULAR SYSTEM

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

NURS 6512 Discussion Week 8 Assessing Musculoskeletal Pain Sample

Presented Case Study: A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform? 

Episodic/Focused SOAP Note 

Patient Information: 

HD, 42 year old Caucasian male 

CC: Lower back pain for the last month 

HPI: HD is a 42-year-old Caucasian male who presents to clinic today for lower back pain that has been occurring for the last month. He states that the pain sometimes radiates to his left leg and feels like an ice pick is going up his leg. He finds that the pain is worse in the mornings and when after he is in the car for an hour during his commute to work and home from work. HD states the pain feels really tight in his lower back. HD rates the pain 5/10 when the pain is occurring, but currently has a 1/10 pain in clinic. HD states that he stopped working out due to the pain 

Current Medications: Lisinopril 10 mg BID for hypertension, Atorvastatin 20 mg once a day for Hyperlipidemia, ibuprofen 800 mg every 8 hours PRN pain, Men’s multivitamin daily 

I would make a point to educate the patient on avoiding NSAIDs for his pain due to her hypertension. It is known that NSAIDs reduce the efficacy of antihypertensive drugs and aggravate pre-exisitng hypertension, along with making the individual prone to develop worsening hypertension through renal dysfunction (Albishri, 2013). Suggesting Tylenol and reviewing proper dosage and frequency would be the next step. 

Allergies: Sulfa (hives), Levaquin (hives), codeine (nausea and vomiting), dust and pollen (Seasonal allergies resulting in itchy ears and throat), dog dander (itchy ears and throat). 

PMHx: HD is up to date on all vaccinations but did not receive his flu vaccine or COVID vaccine this year. Received a tetanus vaccine in 2019 due to a saw injury on his farm. He has no major past surgical history. Endorses he had a vasectomy 5 years ago after his third child was born. He has hypertension and hyperlipidemia and is followed by a cardiologist and is seen every six months.  
 
Soc Hx: HD is an engineer and works downtown Monday-Friday. He has an office job and states that his only exercise is to and from his car up to his work building. HD states he tried to start brisk walking with his wife, but it really aggravated his lower back, so he stopped. He drinks alcohol and states he drinks daily and has about 8 beers a day on the weekend, during the week mostly consists of scotch/whiskeys. He denies smoking cigarettes but states he does have a cigar once a week. He denies engaging in illicit drugs. HD recalls his last meal as two breakfast tacos and a large coffee. HD states that he follows a hearty German diet and does not consume any greens or fruits and sticks to mostly cheese and meat. HD has three children and a wife who all live in the home. He states he has guns in the home, but they are properly locked up. 

Fam Hx: Mother: Breast cancer (deceased), Father: Hypertension, AVN of bilateral hips, received a total hip replacement of both hips at different times in his mid 40’s (living), Maternal grandmother: Hypertension (Deceased), Maternal Grandfather: Prostate cancer (deceased), Paternal grandmother: hypertension (living), paternal grandfather: hypertension and stroke (deceased). States his brother has Avascular necrosis of his right hip, and got a total hip replacement at age 40 (3 years ago). His sister passed away as a child due to an unknown virus. 

ROS: cover all body systems that may help you include or rule out a differential diagnosis 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. 

Example of Complete ROS: 

GENERAL:  42 well appearing male, a&o4 and maintains eye contact during interview and exam, denies fatigue, night sweats, chills, fever 

            Vital Signs: 180/72, HR: 79, RR: 18, O2: 100% on room air, Temp: 98.7F, pain: 1/10 

HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclerae, wears contacts and glasses. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose, or sore throat. 

SKIN:  No rash, lesions, abnormal moles, denies itching. 

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema. 

RESPIRATORY:  No shortness of breath, cough or sputum. 

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. 

GENITOURINARY:  Denies burning on urination. Endorses vasectomy 5 years ago. 

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. 

MUSCULOSKELETAL:  Endorses lower back pain that radiates to his left leg. Denies numbness in legs, full range of motion noted in LUE, RLE, & RUE, a slight change of range of motion is noted in the LLE upon different adduction and flexion maneuvers, no swelling at joints noted. 

HEMATOLOGIC:  No anemia, bleeding or bruising. 

LYMPHATICS:  No enlarged nodes. No history of splenectomy. 

PSYCHIATRIC:  No history of depression or anxiety. 

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. 

ALLERGIES:  Sulfa and Levaquin, dog dander, and seasonal allergies to pollen and dust 

Physical exam: 

General: A&OX4, PERRLA, follows commands, converses well and is appropriate 

Cardiovasc: S1 S2 auscultated, no murmurs or rubs, regular rhythm, no edema or fluid retention in all extremities, cap refill <3 in all extremities. 

Resp: Clear breath sounds in all lung fields, regular respiratory rate, no accessory muscle usage 

Musculoskeletal:  no swelling at joints, pain noted when patient rises from squat position and walked on toes, pain rated 3/10 noted during flexion and adduction in LLE.  

Gastro: Normoactive bowel sounds in all quadrants, no tenderness upon light and deep palpation 

Diagnostic results: Total abdominal and pelvic x-ray, a CT and MRI, as well as EMG. This is the more radical route; some providers may choose to not engage in any imaging. Choosing Wisely Canada recommendations state that it is not necessary to do imaging for lower-back pain unless red flags are present, such as severe or progressive neurological deficits or osteomyelitis is suspected (Furlan & Murphy, 2016). Knowing the typical red flags of back pain (weakness, bowel and bladder incontinence, or pain that awakens a patient from sleep) in adults and children can guide providers to appropriate evaluation and treatment, leading to the best most therapeutic management for the affected patient (Casiano, et al, 2023). 

1. A.

Differential Diagnoses  

1. Piriformis Syndrome: This syndrome is caused by a swollen piriformis that compresses the sciatic nerve, producing hip pain that radiates down into the lower limb, and is made much worse by driving and sitting (Guiffre, Black & Jeanmonod, 2023). Treatment includes short-term rest that does not exceed more than 48 hours, muscle relaxants, NSAIDs and physical therapy, and in some patients, injection therapy of steroids around the piriformis muscle can aid in decreasing inflammation and pain (Hicks, Lam, & Varacallo, 2023). Interestingly enough, Botox has started to become a common route of therapy, and is aimed at relieving sciatic nerve compression and inherent muscle pain from a tight piriformis (Kirschner, Foye, & Cole, 2009). 

1. Sciatica: This is a result of pain that travels down the path of the sciatic nerve, going through the lower back into the hips and buttocks and down each leg resulting in inflammation that results in pain and sometimes numbness (Mayo Clinic, 2022). Furthermore, sciatica occurs when the sciatic nerve becomes pinched usually due to a herniated disc in the spine or overgrowth in the bone, and although rare, a tumor can place pressure on the nerve or even damage from diabetes (Mayo Clinic, 2022). 

1. Herniated Lumbosacral disc: Degenerative disc disease and lumbar disc herniation are the most common culprits of lower back pain, with approximately 95% of disc herniations occurring in the L4-L5, or L5-S1 area (Qaraghli & Jesus, 2023) 

1. Muscle Spasm: Lower back spasms can result from poor posture, muscle overuse, sprains and strains, and can often radiate to other parts of the body such as the hips and legs (Villines, 2023). Treatment for this usually depends on the cause of symptoms, but recommendations include pain medications, physical therapy, and if these routes fail, surgery to repair damaged discs or a spinal decompression surgery (Villines, 2023). 

1. Avascular Necrosis: Hip osteonecrosis may contribute to atypical presentation of lower back pain due to aberrant localization of pain that is combined with altered biochemical loading on musculoskeletal structures (Minkalis & Vining, 2015). A simple pelvic x-ray can rule this condition out, and if positive, futher imaging will be ordered such as CT and MRI.  

What nerve roots might be involved? 

Lumbar nerve pain (sciatica) can be a combination of back and leg pain (Penn Medicine, n.d.). The most common nerves that are usually pinched in the lower back are L5 and S1, and these are spinal nerve roots that are at a higher risk of being irritated or compressed (Scisoscia, 2017). 

How would you test for each of them? What physical examination will you perform?  

What special maneuvers will you perform? 

Some tests that can be done include the FAIR test, the Beatty Maneuver, Pace maneuver test, and the Freiberg maneuver (Yetman, 2021). The Freiberg maneuver is forceful internal rotation of an extended thigh, the Pace maneuver is when there is a resisted abduction and external rotation of the thigh, the Beatty maneuver causes deep buttock pain produced by the side-lying patient holding a flexed knee several inches off the table, and the FAIR maneuver stands for flexion, abduction, internal rotation (Hicks, Lam, & Varacall, 2023). Furthermore, other imaging techniques like MRI, CT and EMG scans can also help differentiate any other possible diagnoses that cause similar symptoms (Yetman, 2021). The EMG approach has been used to diagnose piriformis syndrome by noting the presence of H waves, and MRI may show the presence of irritation of the sciatic nerve just adjacent to the sciatic notch(Hicks, Lam & Varacall, 2023). Another test is the Lesegue sign test, which is a clinical sign that commonly is used in physical exams with patients who have lower back pain, and it tests for lower lumbosacral nerve root irritation (Kamath & Kamath, 2017). 

Consider what history would be necessary to collect from the patient in the case study you were assigned. 

It would be wise to follow up on his family history with his father and brothers Avascular Necrosis diagnosis. Although most cases of AVN are sporadic, idiopathic familial cases have been reported so far with some families having multiple affected members (Pouya & Kerachian, 2015). 

References 

Al Qaraghli, M. I., & De Jesus, O. (2020). Lumbar Disc Herniation. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560878/  Links to an external site. 

Albishri, J. (2013). NSAIDs and hypertension. PAIN & INTENSIVE CARE, 17(2). https://applications.emro.who.int/imemrf/Anaesth_Pain_Intensive_Care/Anaesth_Pain_Intensive_Care_2013_17_2_171_173.pdf  Links to an external site. 

Casiano, V., & De, N. (2023). Back Pain. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538173/  Links to an external site. 

Furlan, A. D., & Murphy, L. (2015). A 46-year-old man with acute low-back pain. Canadian Medical Association Journal, 188(6), 441–442. https://doi.org/10.1503/cmaj.150660  Links to an external site. 

Hicks, B. L., Lam, J. C., & Varacallo, M. (2020). Piriformis Syndrome. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448172/  Links to an external site. 

Giuffre, B. A., & Jeanmonod, R. (2022, July 25). Anatomy, Sciatic Nerve. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482431/  Links to an external site. 

Kamath, S. U. (2017). Lasègue’s Sign. JOURNAL of CLINICAL and DIAGNOSTIC RESEARCH, 11(5). https://doi.org/10.7860/jcdr/2017/24899.9794  Links to an external site. 

Kirschner, J. S., Foye, P. M., & Cole, J. L. (2009). Piriformis syndrome, diagnosis and treatment. Muscle & nerve, 40(1), 10–18. https://doi.org/10.1002/mus.21318 

Minkalis, A. L., & Vining, R. D. (2015). What is the pain source? A case report of a patient with low back pain and bilateral hip osteonecrosis. The Journal of the Canadian Chiropractic Association, 59(3), 300–310. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4593036/ Links to an external site. 

Nerve Root Pain – Symptoms and Causes. (n.d.). Www.pennmedicine.org. https://www.pennmedicine.org/for-patients-and-visitors/patient-information/conditions-treated-a-to-z/nerve-root-pain Links to an external site. 

Pouya, F., & Kerachian, M. A. (2015). Avascular Necrosis of the Femoral Head: Are Any Genes Involved? Archives of Bone and Joint Surgery, 3(3), 149–155. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4507066/#:~:text=Inherited%20Avascular%20Necrosis Links to an external site. 

Sciatica – Symptoms and causes. (2022, September 13). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/sciatica/symptoms-causes/syc-20377435#:~:text=The%20sciatic%20nerve%20travels%20from   Links to an external site. 

Scioscia, T., & Español, O. S. P.-R. |. (2017, August 24). Spinal Cord and Spinal Nerve Roots | Spine-health. Www.spine-Health.com. https://www.spine-health.com/conditions/spine-anatomy/spinal-cord-and-spinal-nerve-roots#:~:text=The%20L5%20and%20S1%20spinal Links to an external site. 

Villines, Z. (2022, December 1). Causes and treatment of lower back spasms. Medical News Today. https://www.medicalnewstoday.com/articles/321916 Links to an external site.