Assignment: NURS 6512 Advanced Health Assessment and Diagnostic Reasoning

Assignment: NURS 6512 Advanced Health Assessment and Diagnostic Reasoning

Assignment: NURS 6512 Advanced Health Assessment and Diagnostic Reasoning

Week Six: Assessment of Heart, Lungs, and Peripheral Vascular System.

Patients presenting with reports of chest pain can be in a life-threatening condition. Urgent and appropriate assessment to identify critical situation is crucial to immediate treatment can be initiated. In this discussion, the assessment techniques to recognize abnormal findings in the area of chest and lungs will be evaluated. The case of Mr. Hendricks in the second scenario of this week’s media will be reflected in an Episodic/Focused SOAP Note format.

ORDER A CUSTOMIZED, PLAGIARISM-FREE Assignment: NURS 6512 Advanced Health Assessment and Diagnostic Reasoning HERE

Episodic/Focused SOAP Note for Case # 2

Review of case study #2

Scenario: Mr. Hendricks presents with reports of consistent sharp chest pain that worsens when taking a full breath.

Patient Information: M.H.        Age: 60 y.o.        Sex: Male

S.

CC: “My chest hurts and it worsens when I take full breath, I feel like my heart is racing.”

HPI: Mr. Hendricks is a 60-year-old Caucasian who presented with reports of sharp and consistent chest pain for the past 6 hours. According to the patient, the pain level ranges from 6/10 to 9/10 which worsens when he takes deep respirations which makes him feel short of breath. The patient stated that he felt like his heart is racing and did not feel any relief with rest or positioning. Prior to arrival, the patient reported that he had episodes of cough with hemoptysis 3-4 hours ago and his wife had noticed his right leg to be swollen and reddened. Mr. Hendricks reported 5/10 pain on his right leg but unsure when the pain started as he was sitting on the plane for eight hours last night. Denies recalling any accident or trauma that may cause his leg to have an injury. No recent hospitalization, surgery or medication changes were reported. Current Medications:

• Fish Oil 1,000mg Capsule once daily
• Atorvastatin 40mg once daily at night
• Lisinopril 40mg once daily

Allergies: Penicillin-rash

Past Medical History:

• Hypertension –controlled with medications (diagnosed 2014)
• Hyperlipidemia – managed with medication and lifestyle modification (diagnosed 2015).

Family History: Both parents deceased. Father died at 97 years old, he does not recall any medical condition. Mother died at 80 years of age, diagnosed with cervical cancer. He has two siblings, no significant medical conditions reported.

He has two children who are 35 years of age and 38 years-of age, no health issues reported.

Personal/Social History:

Both patient and wife are self-employed. Denies smoking and alcohol use.

Review of Systems:

GENERAL:  A&O x4, cooperative. Appears anxious. Denies weight loss, fever, weakness, or fatigue.

HEENT:  Denies headache or sore throat. Patient wears glasses and is up to date with his annual eye exam. No visual changes, Denies hearing difficulties.

SKIN: Redness and swelling on RLE. No rash or itching. No bruising.

CARDIOVASCULAR:  Sharp and consistent chest pain ranging from 6 to 9 out of 10. Not relieve by rest or positioning. Palpitations with full breath. Swelling and redness of RLE.

RESPIRATORY: Reports shortness of breath accompanying chest pain for past 6 hours, Episode of nonproductive cough with small blood-tinged sputum. Denies congestion. No recent exposure to individuals with respiratory infection.

GASTROINTESTINAL:  No change in appetite. Denies abdominal discomfort or change in bowel pattern.

GENITOURINARY:  No change in urinary pattern. Denies dysuria or hematuria.

NEUROLOGICAL:  Denies headache, dizziness, weakness, syncope or change in sensation.

MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC: Episode of one time blood-tinged sputum. No symptoms of active bleeding reported. No anemia or bruising.

LYMPHATICS:  No enlarged nodes. No cervical lymphadenopathy

PSYCHIATRIC:  No history of depression or anxiety. No change in behavior reported.

ENDOCRINOLOGIC: No polyuria or polydipsia.

ALLERGIES:  Penicillin-Rash

O.

Physical exam: Vital signs: B/P 148/88, Pulse 112bpm (Fast and irregular); Temp 97.9F orally; RR 32; labored; SpO2: 90% room air; Wt: 210lbs; Ht: 5’7

General: A&O x4, cooperative. Appears anxious and minor respiratory distress. Good historian. Well-developed and Well-nourished.

HEENT: Normocephalic and atraumatic. Sclera anicteric, PERRLA, oropharynx red, moist mucous membranes. No facial drooping.

Neck: No pain, swelling or palpable nodules. No carotid bruits

Chest/Lungs: Diminishes breath sounds on the right and middle lower lobes. No adventitious breath sound on left lung. Thorax symmetrical. No tactile fremitus. No wheezes, rales or rhonchi. Vesicular breath sounds.

Heart/Peripheral Vascular: Rate of 112bpm. Tachycardia. Strong and irregular rate noted. No significant S1 and S2 sounds. No rubs, gallops or murmurs. +2 edema on RLE. Bilateral equal pedal pulses.

ABD: Soft, non-tender, non-distended. Bowel sounds present and normoactive in all four quadrants.

Genital/Rectal: continent of bladder and bowel. No Foley catheter.

Musculoskeletal: 5/10 pain on the RLE calf. +2 edema on RLE. Normal range of motion. Normal muscle mass for age. No joint deformities.

Neuro: Alert and oriented x4. Strength and sensation intact. No balance deficit.

Skin/Lymph Nodes: No cervical lymphadenopathy. No rashes. Warm erythema with +2 edema on RLE.

Diagnostic results:

Laboratory studies:

CBC – WBC 7.9; H/H: 12.6/37.8; PLT: 200

Coagulation studies: PT/INR: 14sec./1.1; PTT:34.3sec.

D-Dimer: 0.80ug/mL (elevated)

A D-dimer test measures a substance in the blood that’s released when a blood clot breaks down. High levels of the substance may mean a clot is present (National Heart, Lung, and Blood Institute, 2014).

Troponin: <0.01

A troponin test measures the levels troponin T or troponin I proteins in the blood which are released when the heart muscle has been damaged, such as occurs with a heart attack (U.S. National Library of Medicine, 2015).

EKG: Sinus tachycardia with non-specific T waves.

Bilateral lower extremity venous Doppler: Right lower extremity deep venous thrombosis present.

Chest X-ray: showed a small pleural effusion on the right base. The right diaphragm is elevated.

Evidence of pleural air can be an indication of pneumothorax whereas, parenchymal infiltrate may suggest pneumonia (Baumann, Dains, & Scheibel, 2016, p. 89).

Ventilation-perfusion (V/Q) scanning: the first line diagnostic tool for detecting pulmonary embolism which uses a radioactive substance to show how good oxygen and blood are flowing to the lungs (Baumann, Dains, & Scheibel, 2016, p. 89). In the incident of pulmonary embolism: report of high probability will show on the test.

CT ANGIOGRAM PULMONARY: prominent main pulmonary artery segment evidence of pulmonary embolus. No evidence of thoracic aortic aneurysm.

A.

Differential Diagnoses (DD):

• Pulmonary embolism: is a sudden blockage in a lung artery which usually begins by a blood clot in a deep vein of the leg that travels to the lung from a vein in the leg with major causes like prolonged sitting, immobility, and post surgeries (National Heart, Lung, and Blood Institute, 2014). Signs and symptoms of pulmonary embolism (PE) include unexplained shortness of breath, problems breathing, chest pain, coughing, or coughing up blood and irregular heartbeat (National Heart, Lung, and Blood Institute, 2014). As all these symptoms are present with Mr. Hendricks pulmonary embolism is the primary diagnosis for the patient.
• Pneumothorax: results from the presence of air or gas in the pleural cavity with unexplained persistent tachycardia and breath sounds over pneumothorax are distant (Ball, Dains, Flynn, Solomon, & Stewart, 2015, p. 288). Although the presence of tachycardia can be a sign of pneumothorax, the absence of pleural air on chest x-ray result and patient’s contributory factors do not indicate a presence of pneumothorax.
• Pericardial effusion: can result from inflammation of the pericardium (pericarditis) in response to illness or injury with symptoms such as dyspnea, orthopnea and chest pressure (Mayo Foundation for Medical Education and Research, 2017). Diagnostic tests may reveal patterns that suggest tamponade on EKG and enlarged heart silhouette if the amount of fluid in the pericardium is large can be seen in chest x-ray (Mayo Foundation for Medical Education and Research, 2017).
• Hemothorax: the presence of blood in pleural cavity which may result from trauma or invasive medical procedure with manifestations such as dyspnea, lightheadedness tachycardia and hypotension (Ball, Dains, Flynn, Solomon, & Stewart, 2015, p. 289).
• Myocardial infarction: is caused by a blood clot that blocks one of the coronary arteries that brings blood and oxygen to the heart with chest pain as the most common manifestation. A physical exam may reveal abnormal lung sounds and a heart murmur, or other abnormal sounds (U.S. National Library of Medicine, 2015).
• Pneumonia: a lung infection caused by bacteria, a virus or fungi with common symptoms such as cough, fever, chills including shortness of breath and abnormal lung sounds can be heard during the physical exam (American Lung Association, 2016).

NURS 6512: Advanced Health Assessment and Diagnostic Reasoning

Reference

American Lung Association. (2016, October). Pneumonia. Retrieved from http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/pneumonia/

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Baumann, L. C., Dains, J. E., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Mayo Foundation for Medical Education and Research. (2017, August 10). Pericardial effusion. Retrieved from

National Heart, Lung, and Blood Institute. (2014, January). Pulmonary Embolism. Retrieved from https://www.nhlbi.nih.gov/health-topics/pulmonary-embolism

U.S. National Library of Medicine. (2015, April). Heart attack. Retrieved from https://medlineplus.gov/ency/article/000195.htm

U.S. National Library of Medicine. (2015, October). Troponin test. Retrieved from https://medlineplus.gov/ency/article/007452.htm

NURS 6512: Advanced Health Assessment and Diagnostic Reasoning

ORDER A CUSTOMIZED, PLAGIARISM-FREE Assignment: NURS 6512 Advanced Health Assessment and Diagnostic Reasoning HERE

Episodic/Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

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:  No weight loss, fever, chills, weakness or fatigue.

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

SKIN:  No rash or 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:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

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

MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness.

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:  No history of asthma, hives, eczema or rhinitis.

O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)

A.

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6^th edition formatting.

NURS 6512: Advanced Health Assessment and Diagnostic Reasoning