DIGITAL CLINICAL EXPERIENCE: FOCUSED EXAM: CHEST PAIN Template documentation

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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 Reasoning media 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?

Required Learning:

  • Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). St. Louis, MO: Elsevier Mosby.
    • Chapter 14, “Chest and Lungs”
      This chapter explains the physical exam process for the chest and lungs. The authors also include descriptions of common abnormalities in the chest and lungs.
    • Chapter 15, “Heart”
      The authors of this chapter explain the structure and function of the heart. The text also describes the steps used to conduct an exam of the heart.
    • Chapter 16, “Blood Vessels”
      This chapter describes how to properly conduct a physical examination of the blood vessels. The chapter also supplies descriptions of common heart disorders.
  • Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.
    • Chapter 107, “X-Ray Interpretation: Chest (pp. 480–487) (specifically focus on pp. 480–481)
  • Chapter 107, “X-Ray Interpretation: Chest (pp. 480–487)Download “X-Ray Interpretation: Chest (pp. 480–487)
  • Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
    Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
    • Chapter 8, “Chest Pain”Download Chapter 8, “Chest Pain”
      This chapter focuses on diagnosing the cause of chest pain and highlights the importance of first determining whether the patient is in a life-threatening condition. It includes questions that can help pinpoint the type and severity of pain and then describes how to perform a physical examination. Finally, the authors outline potential laboratory and diagnostic studies.
    • Chapter 11, “Cough”Download Chapter 11, “Cough”
      A cough is a very common symptom in patients and usually indicates a minor health problem. This chapter focuses on how to determine the cause of the cough by asking questions and performing a physical exam.
    • Chapter 14, “Dyspnea”Download Chapter 14, “Dyspnea”
      The focus of this chapter is dyspnea, or shortness of breath. The chapter includes strategies for determining the cause of the problem through evaluation of the patient’s history, through physical examination, and through additional laboratory and diagnostic tests.
    • Chapter 26, “Palpitations”Download Chapter 26, “Palpitations”
      This chapter describes the different causes of heart palpitations and details how the specific cause in a patient can be determined.
    • Chapter 33, “Syncope”Download Chapter 33, “Syncope”
      This chapter focuses on syncope, or loss of consciousness. The authors describe the difficulty of ascertaining the cause, because the patient is usually seen after the loss of consciousness has happened. The chapter includes information on potential causes and the symptoms of each.
  • Bansal, M. (2020). Cardiovascular disease and COVID-19.Links to an external site. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 14(3), 247–250. https://doi.org/10.1016/j.dsx.2020.03.013

Links to an external site.

Links to an external site.

Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

 

Brain Foster 58 y/o Caucasian male 

Subjective

Pt. reports: “I have been having some troubling chest pain in my chest now and then for the past month.” Experiencing periodic chest pain with exertion such as yard work, as well as with overeating. Points to midsternum as location. Describes pain as “tight and uncomfortable” upon movement or exertion. Mentioned an episode upon going up the stairs to bed. Most recent episode was three days ago after eating a large restaurant dinner. Denies radiation. Pain lasts for “a few” minutes and goes away when he rests. States “It has never gotten ‘really bad’” so he didn’t think it was an emergency but is concerned after three episodes in one month and wants his heart checked out. Last physical was 1 year ago but says he hadn’t been checked out for several years prior. His regular diet includes grilled meat, some sandwiches, and vegetables. Reports grilling between 4-5 times a week, usually red meat. Has fast food for lunch on busy days. 1-2 cups of coffee a day. Denies coughing, shortness of breath, indigestion, heartburn, jaw pain, fatigue, dizziness, weakness, nausea, vomiting, and diarrhea. Denies chest pain at time of interview. No history of anxiety or depression. 

Medications: Lisinopril 20 mg po daily, Atorvastatin 20 mg po daily at bedtime, last dose yesterday, omega-3-Fish Oil 12000 mg po BID, last dose 8 am and takes Ibuprofen 400 mg po prn Q4hrs for pain 

Allergies: Codeine (Nausea and vomiting)

Immunizations: Tdap 10/2014, influenza vaccine this season

Medical History: HTN-stage II, diagnosed 1 year ago, Hyperlipidemia- diagnosed 1 year ago. No surgical history

Family history: HTN, Hyperlipidemia, Obesity, colon cancer, DMII, Breast cancer, Pneumonia, Asthma, Myocardial infraction (MI).

Social history: Denise use of tobacco use, denies use of marijuana, cocaine, heroin, or other illicit drugs. Drinks 2-3 alcoholic beverages (beer) per week

Objective

• General Survey: Alert and oriented, with clear speech. Sitting comfortably in no acute distress. • Cardiac: S1, S2, without murmurs or rubs. S3 noted at mitral area. No swelling or fluid retention present. • Peripheral Vascular: No JVD present. JVP 3 cm above sternal angle. Left carotid no bruit. Right side carotid bruit. Right carotid pulse with thrill, 3+. Brachial, radial, femoral pulses without thrill, 2+. Popliteal, tibial, and dorsalis pedis pulses without thrill, 1+. Cap refill less than 3 seconds in all 4 extremities. • Respiratory: Breathing is quiet and unlabored. Breath sounds are clear to auscultation in upper lobes and RML. Fine crackles in posterior bases of L/R lungs. • Gastrointestinal: Round, soft, non-tender with normoactive bowel sounds in all quadrants; no abdominal bruits. No tenderness to light or deep palpation. Tympanic throughout. Liver is 7 cm at the MCL and 1 cm below the right costal margin. Spleen and bilateral kidneys are not palpable. • Neuro: Alert and oriented x 3, follows commands, moves all extremities. Gross cranial nerves 2-12 bilaterally and grossly intact. • Skin: Warm, dry, pink, and intact. No tenting and no sweating. • Musculoskeletal: Moves all extremities. • Psych: Normal affect, cooperative, good eye contact. • EKG (interpretation): Regular sinus rhythm. No ST changes. 

Assessment

Based on the abnormal findings during cardiovascular and respiratory auscultation, my differentials include coronary artery disease with stable angina; congestive heart failure; carotid disease; aortic aneurysm; pericarditis; or GERD. 

Vital Signs

36.7C, 146/90, 104, 19, 98% RA

Weight: 197 Ibs

Height: 5’11”

 

Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1).

Plan

Mr. Foster should receive a 12-lead ECG, chest x-ray, and lab workup (cardiac enzymes, electrolytes, CBC, BNP, CMP, Hgb A1C, lipid profile, and liver function tests) to confirm a diagnosis. He should be referred for an echocardiogram, exercise stress test, and carotid dopplers as well as a consult with a vascular surgeon for carotid evaluation. Mr. Foster should be prescribed diltiazem and a diuretic in addition to his daily lisinopril and atorvastatin. If needed, add an ACE inhibitor to manage his hypertension and PRN nitroglycerin for chest pain that does not subside with rest.
 

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