NURS 6512 Week 7 Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation
NURS 6512 Week 7 Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation
Week 7 Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation
SUBJECTIVE DATA: B.F Age: 58, Sex: Male, Race: Caucasian
Chief Complaint (CC): The patient presents with a chief complaint of troubling chest pains that have been happening now and then for the past month.
History of Present Illness (HPI): Mr. B.F. is a 58-year-old man who presents with a concern of having periodic pains now and then. The pains are located at the mid-sternum chest pain region. He reports he has never treated it as an emergency, but in the past month, she has experienced three episodes that have raised his concern. He described the pain as tight and uncomfortable, especially with movement and exertion. He also reports that the pain happens during labor, such as yard work, and is relieved when he lays down and rests. He states that the last episode occurred three days ago after eating a larger meal. De reports that the pain stays for a few minutes and goes away. When they happen, he rates the pain at a five on a scale of 0-10. He states he is not currently taking any medication for his chest pain.
Medications:
- Atrorvastatin 20 mh per day
- Lisinopril 20 mg per day.
Allergies: Denies any food or latex energy.
Past Medical History (PMH): None reported
Past Surgical History (PSH):
Sexual/Reproductive History: The patient is a heterosexual male who denies STDs or genital issues.
Personal/Social History: The patient is married and lives with his wife in their home. He reports drinking alcohol conditionally. He also denies any use of tobacco or any other illicit drug. The patient reports to be watching his diet and drinks water regularly.
Immunization History: Is up-to-date with all childhood and current immunizations.
Significant Family History: Denies any family history of heart conditions, pericarditis, pneumonia, and coronary artery disease.
General: No reported weakness, fatigue, fever, chills, weight changes, and night sweats.
Cardiovascular/Peripheral Vascular: Denies any palpitations or heart murmurs. No reported chest tightness
Respiratory: Denies wheezing, coughing, or difficulty in breathing.
Gastrointestinal: Denies any changes in bowel movement. Denies vomiting, nausea, diarrhea, stomach upsets or constipation
Musculoskeletal: Denies any joint pain or swelling; denies any muscle and back pains. Movement in all extremities.
Psychiatric: Is alert and oriented.
Skin and hair. He denies any itching, skin lesions, or any skin problems.
Physical Exam:
Vital signs: BP: 146/90, HR: 104, RR: 19, SAT: 98%, WT: 197, HT: 5’11
General: The patient is seated upright, alert, and oriented with no acute distress.
Cardiovascular/Peripheral Vascular: S1. S2, audible, and S3 were noted in the mitral area. No swelling or fluid retention was noticed. No bruit noted over abdominal aorta, renal, iliac, or femoral arteries; no lower extremity edema.
Respiratory: Breathing is quiet and unlabored. Breath sounds clear to auscultations in the upper lobes and RML. Fine crackles in posterior bases of lungs.
Gastrointestinal: Round, soft, and non-tender bowel with normoactive bowel sounds in all quadrants. No abnormal bruits. No tenderness in light and deep palpitations. The liver is palpable. Spleen, non-palpable
Musculoskeletal: All extremities move as required
Neurological: Alert and oriented and follows instructions as directed.
Skin: Moist and dry with no observable lesions
Diagnostic Test/Labs:
- X-ray- the test is necessary to confirm the diagnosis
- Lab workup; This is important to help identify other diagnoses.
- 12-lead ECG test
ASSESSMENT:
Coronary artery disease with stable angina (typical angina or angina pectoris): Angina pectoris manifests through chest discomfort or anginal equivalent, primarily provoked with exertion and alleviated at rest or with nitroglycerin, representing the first warning signs of underlying coronary disease (Gillen & Goyal, 2021). This diagnosis is highly appropriate based on the abnormal findings after cardiovascular and respiratory auscultations. According to Rousan & Thadani (2019), patients with stable angina may experience pain during exercise and effort tolerance. Mr. Brian reports experiencing these pains during exertion.
Congestive heart failure: This condition is exacerbated by structural abnormalities of the heart and other risk factors, including aging, family history, unhealthy lifestyle habits, and underlying infections like SARS-COV-2. According to King & Goldstein (2022), the clinical manifestation of this condition includes various symptoms like increasing dyspnea on exertion, leg swelling, chest pain, fatigue, anorexia, and exercise intolerance. This is an appropriate diagnosis based on the abnormal findings during the auscultation of the patient’s cardiorespiratory system.
GERD: Gastroesophageal reflux disease (GED) is a chronic gastrointestinal condition that manifests through nausea, dysphagia, odynophagia, epigastric pain, and belching (Antunes, Aleem & Curtis, 2022). Based on the abnormal findings, this is a likely diagnosis. As stated by Clarrett & Hachem (2018), GERD is a common cause of chest pains, and this is presented by Mr. Brian, who reports having experienced an episode three days ago after eating a large meal.
References
Antunes, C., Aleem, A., & Curtis, S. A. (2021). Gastroesophageal reflux disease. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441938/#
Clarrett, D. M., & Hachem, C. (2018). Gastroesophageal reflux disease (GERD). Missouri Medicine, 115(3), 214–218. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6140167/
Gillen, C., & Goyal, A. (2021). Stable angina. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559016/
King, K., & Goldstein, S. (2022). Congestive heart failure and pulmonary edema. StatPearls. https://www.statpearls.com/ArticleLibrary/viewarticle/19880
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 Review, 14(1), 18–22. https://doi.org/10.15420/ecr.2018.26.1
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Week 7 Assignment One DCE
In order to adequately assess the chest region of a patient, nurses need to be aware of a patient’s history, potential abnormal findings, and what physical exams and diagnostic tests should be conducted to determine the causes and severity of abnormalities.
In this DCE Assignment, you will conduct a focused exam related to chest pain using the simulation too, Shadow Health. Consider how a patient’s initial symptoms can result in very different diagnoses when further assessment is conducted.
Take a moment to observe your breathing. Notice the sensation of your chest expanding as air flows into your lungs. Feel your chest contract as you exhale. How might this experience be different for someone with chronic lung disease or someone experiencing an asthma attack?
- Review this week’s Learning Resources and the Advanced Health Assessment and Diagnostic Reasoningmedia program and consider the insights they provide related to heart, lungs, and peripheral vascular system.
- Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation with the Shadow Health platform. Review the examples also provided.
- Review the DCE (Shadow Health) Documentation Template for Focused Exam: Chest Pain found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
- Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
- Review the Week 7 DCE Focused Exam: Chest Pain Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
- Consider what history would be necessary to collect from the patient.
- Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
DCE FOCUSED EXAM: CHEST PAIN ASSIGNMENT:
Complete the following in Shadow Health:
- Cardiovascular Concept Lab (Required)
- Respiratory(Recommended but not required)
- Cardiovascular (Recommended but not required)
- Episodic/Focused Note for Focused Exam (Required): Chest Pain
SUBMISSION INFORMATION
- Complete your Focused Exam: Cough DCE Assignment in Shadow Health via the Shadow Health link in Canvas.
- Once you complete your assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding assignment in Canvas for your faculty review.
- (Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You can find instructions for downloading your lab pass here: https://link.shadowhealth.com/download-lab-passLinks to an external site.
- Complete your documentation using the documentation template in your resources and submit it into your Assignment submission link below.
- To submit your completed assignment, save your Assignment as WK7Assgn1+last name+first initial.
- Then, click on Start Assignmentnear the top of the page.
- Next, click on Upload Fileand select both files and then Submit Assignment for review.
Musculoskeletal Pain Week 8
The body is constantly sending signals about its health. One of the most easily recognized signals is pain. Musculoskeletal conditions comprise one of the leading causes of severe long-term pain in patients. The musculoskeletal system is an elaborate system of interconnected levers that provides the body with support and mobility. Because of the interconnectedness of the musculoskeletal system, identifying the causes of pain can be challenging. Accurately interpreting the cause of musculoskeletal pain requires an assessment process informed by patient history and physical exams.
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In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
To prepare:
- By Day 1 of this week, you will be assigned to one of the following specific case studies for this Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
- Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
- Review the following case studies:
Case Study 1 (Back Pain)
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?
OR
Case Study 2 (Ankle Pain)
A 46-year-old female reports pain in both of her ankles, but she is more concerned about her right ankle. She was playing soccer over the weekend and heard a “pop.” She is able to bear weight, but it is uncomfortable. In determining the cause of the ankle pain, based on your knowledge of anatomy, what foot structures are likely involved? What other symptoms need to be explored? What are your differential diagnoses for ankle pain? What physical examination will you perform? What special maneuvers will you perform? Should you apply the Ottawa ankle rules to determine if you need additional testing?
With regard to the case study you were assigned: (1 or 2)
- Review this week’s Learning Resources and consider the insights they provide about the case study.
- Consider what history would be necessary to collect from the patient in the case study you were assigned.
- Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
- Identify at least fivepossible conditions that may be considered in a differential diagnosis for the patient.
Post: an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.
