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.

How to Research and Prepare for NURS 6512 DIGITAL CLINICAL EXPERIENCE: ASSESSING THE HEART, LUNGS, AND PERIPHERAL VASCULAR SYSTEM

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

Sample Answer 3 for NURS 6512 DIGITAL CLINICAL EXPERIENCE: ASSESSING THE HEART, LUNGS, AND PERIPHERAL VASCULAR SYSTEM

Name: Brian Foster

Age: 58 years

Sex: Male

Race: Caucasian

Chief Complaint (CC): “I have been having some troubling chest pain in my chest now and then for the past month.”

History of Present Illness (HPI): Brian Foster is a 58-year-old Caucasian male presenting with troubling chest pain since the last month. The pain is situated in the middle of his chest. Currently, the pain is at zero although he rates the pain at 5/0 during the previous episodes. It is usually a tight uncomfortable feeling that is neither burning nor crushing. He had 3 episodes in the past month. The initial episode commenced with physical activity, while he was doing his yard work whilst the second episode commenced when he was taking stairs at work. The most recent episode was three days ago. These episodes lasted only for a few minutes and they all felt the same. The pain does not radiate to the neck, shoulder, back, or even to the arm and is not associated with food intake. It is aggravated by physical activity and relieved by laying down with a brief rest. Has not taken any medications for the chest pain.

Medications: Metoprolol 100 mg PO once daily, atorvastatin 20 mg PO once daily, and omega 3 fish oil 1200mg PO once daily. He occasionally takes over-the-counter medications particularly Tylenol or Motrin when having headaches. Denies aspirin use.

Allergies: codeine (nausea/vomiting). No known food allergies.

Past Medical History (PMH): He was diagnosed with Stage 2 hypertension a year ago. Also diagnosed with hyperlipidemia last year. Denies regular blood pressure monitoring, history of coronary artery disease, or previous chest pain treatments. Formerly had a heavy EKG but the last one done 3 months ago was normal. He sees his primary care provider every 6 months.

Past Surgical History (PSH): Denies any previous surgeries or blood transfusion.

Sexual/Reproductive History: Heterosexual.

Personal/Social History: Married with two children, the wife is 50 years old and well. Drinks 2 to 3 beers per week although he does not use tobacco or illicit drugs. Has not exercised regularly for 2 years. Unsure of salt intake. Diet mainly consists of granola bars, turkey subs, grilled meat, and veggies. Reports a daily water intake of 1 liter and 1 to 2 cups of coffee daily. No unusual stress was noted.

Immunization History: The last dose of TDAP was 10/2014 while his influenza vaccination is up to date.

Significant Family History: Father had hypertension, hyperlipidemia, and obesity but died at 75 years due to colon cancer. His mother is 80 years old but has type 2 diabetes and hypertension. His brother deceased at 24 years as a result of a motor vehicle accident. His sister is 52 years old and has type 2 diabetes and hypertension. Maternal grandfather experienced a heart attack at the age of 54 years while maternal grandmother died of breast cancer at the age of 65 years. Paternal grandmother succumbed from pneumonia at the age of 75 years while paternal grandfather died aged 85 years due to “old age.” He has a healthy son aged 26 years and an asthmatic daughter aged 19 years.

Review of Systems:

General: Denies fever, chills, weight loss, increased sweating, recent illness, or fatigue.

HEENT: No blurring of vision, hearing problems, runny nose, sore throat, or difficulty in swallowing.

            Cardiovascular/Peripheral Vascular: Denies dizziness, palpitations, peripheral edema, history of angina, or circulation problems

            Respiratory: No cough, shortness of breath, wheezing, or sputum.

            Gastrointestinal: No nausea, loss of appetite, constipation, diarrhea, abdominal pain, bloating, or vomiting.

            Musculoskeletal: No joint pain, swelling, stiffness

Hematological: No anemia, easy bruising, and bleeding.

            Psychiatric: Denies anxiety, hallucinations, or depression.

Skin: No lesions, skin changes, or rashes.

OBJECTIVE DATA:

            Physical Exam:

Vital signs: blood pressure  146/88 mmHg (left arm) and 146/90 mmHg (right arm), mean arterial blood pressure- 109 mmHg. Temperature- 36.7 degrees Celsius, heart rate-104 b/min, respiratory rate-19 breaths/min, oxygen saturation- 98% on room air.

General: A middle-aged Caucasian male, appropriate for his age and well-groomed. He is alert and oriented with no acute distress. Good oral hygiene. Well hydrated and good nutrition status. No cyanosis, jaundice, pallor, lymphadenopathy, or edema.

             Cardiovascular/Peripheral Vascular: Normoactive precordium on inspection. Point of maximal impulse displaced laterally.  S1 and S2 heard. No murmurs or rubs. S3 heard at the mitral area. Right carotid bruit. JVP 3 cm above the sternal angle. Left carotid pulse without a thrill, 2+. Right carotid pulse with bruit and thrill, 3+. Brachial, radial, femoral pulses without a thrill, 2+. Popliteal, posterior tibial, and dorsalis pedis pulses without a thrill, 1+. Capillary refill of all the digits and toes, 2 seconds.

Respiratory: Symmetrical chest that movies with respiration with no obvious chest wall deformities. Non-tender and trachea centrally located. Resonant on percussion. Vesicular breath sounds in the upper lobes and right middle lobe. Fine crackles/rales in posterior bases of right and left lungs.

Gastrointestinal: Symmetrical, round, non-distended abdomen that moves with respiration. Umbilicus inverted with no visible scars or lesions. Soft and non-tender on both light and deep palpation, the liver span is 7 cm in the MCL and 1 cm below the right costal margin. Tympanic on percussion. The spleen and bilateral kidneys are impalpable. Normoactive bowel sounds in all the quadrants and no abdominal bruit on auscultation.

Musculoskeletal: Normal muscle bulk, power grade 5/5 across all muscle groups, normal tone, and normal reflexes. Full range of motion across all joints.

Neurological: GCS 15/15. Oriented to time, place, and person. Intact memory and speech. All cranial nerve functions are intact. Intact sensation across all dermatomes. Intact bladder and bowel function. No spinal tenderness.

Skin: dry, warm, pink, and intact. No tenting.

Diagnostic Test/Labs:

EKG- regular sinus rhythm, no ST changes. Fasting blood sugar and HbA1c to exclude diabetes given his significant family history of type 2 diabetes (Galicia-Garcia et al., 2020). He is on therapy for hyperlipidemia and therefore requires a lipid profile to evaluate the current level of control.  Additional tests include a complete metabolic panel to isolate any underlying electrolyte abnormalities, liver function tests to check liver function, and a complete blood count as a baseline for treatment. Similarly, cardiac enzymes and brain natriuretic peptide are required to exclude myocardial infarction since chest pain can be caused by myocardial infarction. Imaging studies include Doppler ultrasound to assess peripheral pulses, chest x-ray to check for any abnormal opacifications, and echocardiography to determine the ejection fraction or any structural lesions of the heart. Finally, CT angiography to detect any carotid diseases since the right carotid had a bruit.

ASSESSMENT:

Priority Diagnosis

• Angina Pectoris

Differential Diagnosis

• Hypertension
• Hyperlipidemia
• Inactive lifestyle
• Myocardial infarction
• Heart Failure
• Peripheral vascular disease

Brian Foster presents with retrosternal chest pain that worsens with exertion but is relieved by rest. This is typical of angina pectoris. For an unknown reason, his chest pain does not radiate to the neck, jaw, left arm, or shoulder. According to Ferrari et al. (2019), angina pectoris is usually an indication of coronary artery disease. Coronary artery disease refers to an ischemic heart disease resulting from the narrowing of coronary vessels resulting in diminished blood flow to the myocardium. His angina is stable since it follows exertion and is relieved by rest (Ferrari et al., 2019). According to Krittanawong et al. (2020), an estimated 90% of coronary artery disease stems from atherosclerosis. Brian Foster has risk factors for atherosclerosis including hypertension, alcohol intake, male sex, hyperlipidemia, and an inactive lifestyle (Krittanawong et al., 2020).

Brian Foster also has uncontrolled hypertension evidenced by persistently elevated blood pressure despite being on antihypertensives (Oparil et al., 2018). He also experiences occasional headaches which might be a result of elevated blood pressure. He was also diagnosed with hyperlipidemia a year ago. Hyperlipidemia refers to elevated lipid levels in the body. According to Su et al. (2021), hyperlipidemia is a risk factor for several cardiovascular disorders and therefore must be controlled. He is currently on atorvastatin and it is elemental to determine the level of control through a lipid profile. Additionally, Brian Foster has an inactive lifestyle evidenced by a lack of regular physical activity.

Brian Foster could also be having a silent myocardial infarction. Myocardial infarction is a consequence of an imbalance between myocardial oxygen demand and supply (Saleh & Ambrose, 2018). It is a common cause of retrosternal chest pain. However, the lack of ST changes on EKG points towards non-ST elevated myocardial infarction (Saleh & Ambrose, 2018). Similarly, Brian Foster has clinical manifestations of heart failure including an S3, displaced apex beat,  and bilateral crackles/rales (Schwinger, 2021). He also has hypertension and dyslipidemia which are important risk factors for heart failure. Consequently, further assessment is required to exclude this condition. Finally, he could be having a peripheral vascular disease (asymptomatic) due to diminished peripheral pulses.

References

Ferrari, R., Censi, S., & Squeri, A. (2019). Treating angina. European Heart Journal Supplements: Journal of the European Society of Cardiology, 21(Suppl G), G1–G3. https://doi.org/10.1093/eurheartj/suz190

Galicia-Garcia, U., Benito-Vicente, A., Jebari, S., Larrea-Sebal, A., Siddiqi, H., Uribe, K. B., Ostolaza, H., & Martín, C. (2020). Pathophysiology of type 2 Diabetes Mellitus. International Journal of Molecular Sciences, 21(17), 6275. https://doi.org/10.3390/ijms21176275

Krittanawong, C., Kumar, A., Wang, Z., Narasimhan, B., Mahtta, D., Jneid, H., Baber, U., Mehran, R., Tang, W., Ballantyne, C. M., & Virani, S. S. (2020). Coronary artery disease in the young in the US population-based cohort. American Journal of Cardiovascular Disease, 10(3), 189–194. https://www.ncbi.nlm.nih.gov/pubmed/32923100

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

Saleh, M., & Ambrose, J. A. (2018). Understanding myocardial infarction. F1000Research, 7, 1378. https://doi.org/10.12688/f1000research.15096.1

Schwinger, R. H. G. (2021). Pathophysiology of heart failure. Cardiovascular Diagnosis and Therapy, 11(1), 263–276. https://doi.org/10.21037/cdt-20-302

Su, L., Mittal, R., Ramgobin, D., Jain, R., & Jain, R. (2021). Current management guidelines on hyperlipidemia: The silent killer. Journal of Lipids, 2021, 9883352. https://doi.org/10.1155/2021/9883352