NURS 6512 Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System
Sample Answer for NURS 6512 Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System Included After Question
Cardiovascular disease (CVD) is the largest cause of death worldwide. Accounting for 800,000 deaths annually, CVD frequently goes unnoticed until it is too late. Early detection and prevention measures can save the lives of many patients who have CVD. Conducting an assessment of the heart, lungs, and peripheral vascular system is one of the first steps that can be taken to detect CVD and many more conditions that may occur in the thorax, or chest area.
This week, you will evaluate abnormal findings in the area of the chest and lungs. In addition, you will appraise health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system.
Learning Objectives
Students will:
- Evaluate abnormal cardiac and respiratory findings
- Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system
Photo Credit: ANDRZEJ WOJCICKI/Science Photo Library/Getty Images
Learning Resources
Required Readings
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
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.
- Chapter 13, “Chest and Lungs” (pp. 260-293)
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 14, “Heart” (pp. 294-331)
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 15, “Blood Vessels” (pp. 332-349)
This chapter describes how to properly conduct a physical examination of the blood vessels. The chapter also supplies descriptions of common heart disorders.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
- Chapter 8, “Chest Pain” (pp. 81–96)
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” (pp. 118-147)
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 through asking questions and performing a physical exam.
- Chapter 14, “Dyspnea” (pp. 159–173)
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” (pp. 310-317)
This chapter describes the different causes of heart palpitations and details how the specific cause in a patient can be determined.
- Chapter 33, “Syncope” (pp. 390-397)
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.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
- Chapter 8, “Outpatient Charting and Communications” (pp. 173-188)
Note: Download these Adult Examination Checklists and Physical Exam Summaries to use during your practice cardiac and respiratory examination.
McCabe, C., & Wiggins, J. (2010a). Differential diagnosis of respiratory disease part 1. Practice Nurse, 40(1), 35–41.
Retrieved from the Walden Library databases.
This article describes the warning signs of impending deterioration of the respiratory system. The authors also explain the features of common respiratory conditions.
McCabe, C., & Wiggins, J. (2010b). Differential diagnosis of respiratory diseases part 2. Practice Nurse, 40(2), 33–41.
Retrieved from the Walden Library databases.
The authors of this article specify how to identify the major causes of acute breathlessness. Additionally, they explain how to interpret a variety of findings from respiratory investigations.
Required Media
Online media for Seidel’s Guide to Physical Examination
Optional Resources
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
- Chapter 8, “The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts” (Section 1, “Chest Wall, Pulmonary, and Cardiovascular Systems,” pp. 302–433)
Note: Section 2 of this chapter will be addressed in Week 10.
This section of Chapter 8 describes the anatomy of the chest wall, pulmonary, and cardiovascular systems. Section 1 also explains how to properly conduct examinations of these areas.
Discussion: Assessing the Heart, Lungs, and Peripheral Vascular System
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?
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 Discussion, you will consider how a patient’s initial symptoms can result in very different diagnoses when further assessment is conducted.
Note: By Day 1 of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. Also, 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.
To prepare:
With regard to the case study you were assigned:
- Review this week’s Learning Resources and consider the insights they provide.
- 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?
- Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Note: Before you submit your initial post, replace the subject line (“Discussion – Week 6”) with “Review of Case Study” identifying the number of the case study you were assigned.
By Day 3
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 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.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
Read a selection of your colleagues’ responses.
By Day 6
Respond to at least two of your colleagues on two different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.
Submission and Grading Information
Grading Criteria
Post by Day 3 and Respond by Day 6
To participate in this Discussion:
Assignment (Optional): Practice Assessment: Cardiac and Respiratory Examination
It is crucial to diagnose cardiac and respiratory conditions early due to the critical nature of these organs. Before a condition can be diagnosed, an examination must be conducted. Properly conducting a cardiac and respiratory examination requires detailed knowledge of the examination procedure and experience in performing this assessment.
In preparation for the Head-to-Toe Physical Assessment Video due in Week 10, it is recommended that you practice performing a cardiac and respiratory examination this week.
Note: This is an optional practice physical assessment. You do not have to capture a video of this assessment, as no submission is required.
To prepare:
- Arrange an appropriate time and setting with your volunteer “patient” to perform a cardiac and respiratory examination.
- Download and review the Cardiac and Respiratory Checklists provided in this week’s Learning Resources.
- Ensure that you have a stethoscope to perform the examination.
To complete:
- Perform the cardiac and respiratory examination. Be sure to cover all of the areas listed in the checklist and to use the equipment appropriately.
Looking Ahead: Skin, Hair, and Nails, and HEENT Physical Assessment Video
In Week 8, you will videotape yourself conducting a skin, hair, and nails, and HEENT physical assessment.
By Day 7 of Week 8
This video is due. Refer to Week 8 for additional guidance.
Week in Review
This week, you properly applied health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system. In addition, you evaluated abnormal cardiac and respiratory findings using the patient’s history and potential abnormal findings. You also recommended appropriate exams/diagnostic tests to determine causes and abnormalities.
Next week, you will explore how to accurately assess the abdomen and gastrointestinal system.
A Sample Answer For the Assignment: NURS 6512 Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System
Title: NURS 6512 Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System
Episodic/Focused SOAP Note Template
Patient Information:
Initials: MM Age: 65 Sex: Male Race: Caucasian
CC (chief complaint): Shortness of breath
HPI: MM is a 65 year old Caucasian male that comes to the clinic complaining of shortness of breath for the last few days. MM states that his shortness of breath is getting worse and he is tired all the time. MM states he has shortness of breath all the time and is coughing up clear phlegm.
Current Medications: None, was taking diuretic but has stopped taking it.
Allergies: Iodine, seafood
PMHx: Up to date on all shots, flu shot last year 10/18
Soc Hx: Retired school teacher, married for 40 years, current smoker (down to 3 cigarettes a day)
Fam Hx: Mother- HTN, Asthma, Father- CHF, does not know medical history of grandparents.
ROS:
GENERAL: 5 pound weight gain in a week, increasing fatigue, no fever or chills
HEENT: Head: No headaches, Eyes: No visual loss or blurred vision. Ears, Nose, Throat: No drainage, hearing loss, or sore throat.
SKIN: Cool and dry, no rash
CARDIOVASCULAR: No chest pain or discomfort, edema noted to bilateral legs.
RESPIRATORY: Cough producing clear phlegm, constant shortness of breath
GASTROINTESTINAL: No nausea, vomiting, or diarrhea
GENITOURINARY: No burning or discomfort on urination.
NEUROLOGICAL: No numbness or tingling.
MUSCULOSKELETAL: No muscle or back pain.
HEMATOLOGIC: No bleeding or bruising.
LYMPHATICS: No enlarged nodes.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: Allergic to iodine and seafood.
Physical exam: Vital signs- BP 162/90, HR 94, RR 20, Temp 97.9m Ht 6’0, Wt 210
General: MM is a 65 year old male, A&O x4, , calm and cooperative upon interview.
Head: Normal size and position, facial features symmetrical.
Eyes: Visual acuity 20/20 using Snellen chart, Eyes symmetrical, No nystagmus noted.
Neurological: Alert and oriented to person, place, time, and situation. Fluent in English language, thoughts and responses appropriate.
Diagnostic results:
CXR- useful to identify underlying causes of shortness of breath
Blood work- to monitor patient’s lab values in order to make a diagnosis
EKG- to monitor the patient’s heart rhythm
- A.
Differential Diagnoses:
CHF- With the patient’s shortness of breath, weight gain, and edema in lower legs, the patient most likely has a diagnosis of CHF
COPD- this could be the cause of patient’s shortness of breath, but would not account for weight gain or edema that the patient is experiencing.
Lung cancer- patient is a current smoker that has tried to quit unsuccessfully. This could be causing his shortness of breath, but does not coincide with other symptoms patient has.
Pulmonary edema- could be cause of patient’s shortness of breath and is often associated with cardiovascular diagnosis.
Pneumonia- could be cause of patient’s shortness of breath, but would not account for other symptoms. Patient is also coughing up only clear phlegm, which doesn’t suggest infection.
References
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.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
A Sample Answer 2 For the Assignment: NURS 6512 Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System
Title: NURS 6512 Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System
Patient Initials: KK Age: 60 Gender: M
Chief Complaint (CC): “I had severe chest pain this weekend.”
History of Present Illness (HPI): Patient is a 60-year-old Caucasian male with a PMH significant for schizophrenia presenting to the clinic today for ER follow-up. Client has been evaluated at the ER 3 times this past weekend for chest pain. In reviewing ER reports, labs (CBC, CMP, Troponins, and D-Dimer) and diagnostics (EKG, CXR) were within normal findings He reports experiencing chest pain Saturday and Sunday, “like an elephant was sitting on my chest,” with accompanying shortness of breath. He reports chest pain was relieved with administration of lorazepam given at the ER. He is requesting something for his anxiety today.
Medications: Haldol 50mg IM q2weeks, fluoxetine 20mg qd, Tramadol 50mg q6h PRN.
Allergies: Cogentin, Nabumetone
Past Medical History (PMH): Schizophrenia, Major Depressive Disorder, Sciatica. Hospitalization for pneumonia in 2014, Inpatient behavioral health x5; last in 2010.
Past Surgical History (PSH): Appendectomy in 1974.
Sexual/Reproductive History: Heterosexual, sexually inactive for the last 10 years.
Personal/Social History: Hx of methamphetamine abuse; denies current usage, Current smoker of 1 ppd, denies etoh intake, single, resides alone, has in home services 2-4 hours per week.
Immunization History: Tdap 2014, flu 2019, pneumo 2019
Significant Family History: father died of a heart attack, mother schizophrenia and committed suicide, two brothers and one sister with schizophrenia.
Lifestyle: Walks in the community daily, reports support systems of friends and social service agencies, two brothers and one sister no contact, they live out of the state, receives SSDI.
Review of Systems:
HEENT: Negative for headache, eye drainage, ear pain, congestion, sore throat.
Neck: Negative for neck pain.
Breasts: Negative.
Respiratory: Shortness of breath, positive for cough with sputum production, unknown color, “I swallow it.”
Cardiovascular/Peripheral Vascular: Positive for intermittent chest pain; currently 4/10
Gastrointestinal: Negative for abdominal pain, nausea, vomiting.
Genitourinary: Negative for dysuria, frequency, and urgency.
Musculoskeletal: Negative for back pain.
Psychiatric: Schizophrenia. Negative for confusion, hallucinations, self-injury, or suicidal ideas.
Neurological: Negative for dizziness, weakness, numbness.
Skin: Negative for rash.
Hematologic: Negative.
Endocrine: Negative.
Allergic/Immunologic: Negative.
OBJECTIVE DATA:
Physical Exam:
Vital signs: BP 126/84, HR 74, R 26, Sp02 95% RA, Ht 5’9’’, Wt 180 lbs., BMI 26.58.
General: He is alert and oriented to person, place, time, and event. He appears well-developed and well-nourished, dressed appropriately for the weather, smells of cigarette smoke.
HEENT: Normocephalic and atraumatic, conjunctivae without redness or drainage, ears without drainage and tympanic membrane is pearly pink, nose without drainage, throat is red without exudate.
Neck: Normal range of motion, neck supple and midline
Chest: symmetrical chest movements, nasal flaring
Lungs: Rhonchi that clears with cough, prolonged expiration, smokers cough.
Heart: Normal rate, regular rhythm, normal heart sounds, pulses present and palpable
Abdomen: No distention, soft, no tenderness or guarding.
Musculoskeletal: Slow shuffled gait with hunched posture.
Neurological: Alert and oriented to person, place, time, and event; exhibits normal muscle tone.
Skin: No pallor, warm, dry, intact; no rash. Skin between fingers is yellow.
Psychiatric: He appears anxious, answers questions appropriately, good eye contact.
Additional diagnostics needed: Sputum culture and pulmonary function tests
ASSESSMENT:
Bronchitis: Hacking cough that becomes productive, afebrile, adventitious breath sounds that clears with cough, smoker. Order sputum culture and PFTs as chest radiography shows normal findings. Order rescue inhaler and nicotine patches as Client verbalizes wanting to stop smoking.
Pneumonia: Client has history of pneumonia, positive for tachypnea, noisy cough, sputum production; however, currently afebrile and heart rate is within normal limits (physical findings in pneumonia: irritability, fever, tachycardia, tachypnea, inspiratory crackles, asynchronous breathing, pleuritic chest pain, sputum is yellow, green, red in color). Pneumonia needs ruled out.
Anxiety: Client reports symptom of chest pain was relieved with lorazepam when administered at ER. I am declining his request for Rx lorazepam today; he will need to follow-up with his mental health provider.
GERD: Client educated to reduce meal size, avoid high-fat meals, avoid alcohol, stop smoking, wait 3 hours to lay down after eating to prevent aggravating factors.
Costochondritis: pain along sternal border that increases with deep breathing, URI, or physical activity, normal breath sounds.
A Sample Answer 3 For the Assignment: NURS 6512 Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System
Title: NURS 6512 Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System
Episodic/Focused SOAP Note
Patient Information:
J.H., 60yrs, M, Caucasian
CC (chief complaint): J.H. complains of chest pain all the time. SOB. States that he is having pain now. States that taking a full breath makes the pain worse. “pain is really sharp, and it hurts real bad. I just want to get a deep breath in and it feels like my heart is racing” States that nothing makes it better.
HPI:60-year-old Caucasian male c/o chest pain described as sharp that gets worse when taken a breath. SOB. Chest pain and SOB started a few days ago. Coughing up blood x1 this morning. Right leg with some edema, redness, and tender to touch. Went on a vacation and was sitting on a plane for 8 hours. Just return a few days ago. Has not taken any medications. 9/10 on a pain scale.
Current Medications: none
Allergies: NKA
PMHx: had pneumonia in 2018.
Soc Hx: retired Navy sailor. Married. Smokes 3 cigarettes per day. Social drinker. Drinks one 6oz glass of Rum and Coke at events and once every other week, usually on Saturdays. Has one son age 32years old. Live in a suburban area in a one-story home with his wife. Has house alarm and smoke detectors. Wears seatbelt while in a motor vehicle.
Fam Hx: Father deceased 45 years of age at the time of death. Cause of death cardiac arrest. Mother deceased at age 55 years of age. Cause of death breast cancer. One sister age58 healthy. One son 32 years old in the Navy.
ROS:
GENERAL: Stable weight of 210lbs, no fever, chills, weakness, or fatigue. anxious
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or a sore throat. Positive for a cough with blood.
SKIN: No rash or itching. Cool and diaphoretic.
CARDIOVASCULAR: chest pain, tachycardic, HR112, Heart rate is irregular with good S1, S2; no S3 or S4; no murmur. Right calf with 2+ edema, erythema; warmth and tenderness on palpation noted; left lower extremity without edema or erythema; 2+ dorsalis pedis pulses bilaterally.
RESPIRATORY: SOB. Respiratory rate: 32, labored. Oxygen saturation: 90% on room air.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: No burning on urination.
NEUROLOGICAL: Alert and oriented to time, place, and person. No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: pain in right calf. Edema and redness in the right calf. Left calf without pain, redness, and edema.
HEMATOLOGIC: No anemia, bleeding or bruising. Blood noted in sputum.
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.
Physical exam: Temp: 97.9 oral. B/P148/88. HR 112. Heart rate is irregular with good S1, S2; no S3 or S4; no murmur. Right calf with 2+ edema, erythema; warmth and tenderness on palpation noted; left lower extremity without edema or erythema; 2+ dorsalis pedis pulses bilaterally. Thorax and lungs: Thorax symmetrical; diminished breath sounds right middle and lower lobes; no rales, rhonchi, or wheezes; breath sounds vesicular with no adventitious sounds left lung. Abdomen: Protuberant with normoactive bowel sounds auscultated x4 quadrants.
Diagnostic results: VQ Scan: Ventilation-perfusion evaluates the airflow (ventilation) and blood flow (perfusion) in the lungs for a suspected pulmonary embolus in the lungs (Jong, 2018). Positive for pulmonary embolus in right lower lung.
Ultrasound: most common test for diagnosing deep vein blood clots. It uses sound waves to create pictures of blood flowing through the arteries and veins (Medline Plus, 2011). Positive for DVT in the right calf.
Chest X-Ray: clear. R/O TB. Secondary to hemoptysis.
- A.
Differential Diagnoses:1. Pulmonary embolus. One of the first signs of a pulmonary embolus is sharp, stabbing chest pains that get worse when breathing (Crosta, 2018). The patient stated in his chief complaint that his chest pain is sharp and gets worse with breathing. Long periods of bed rest or inactivity increase the risk of DVT (Crosta, 2018). The patient stated that he was on a flight for eight hours.
2.Deep vein thrombus(DVT). Maybe related to pulmonary embolus. Sign and symptoms of a DVT are swelling in the leg, redness, warmth, and tenderness (Medline Plus, 2011). The patient had pain in right calf, edema, redness, and was tender to touch.
- Bacterial Pneumonia. The most common sign and symptom is a cough with thick blood tinged mucus and stabbing chest pain that worsens when coughing or breathing (Chase, Leonard, & Gotter, 2017). The patient had a cough with blood in the morning.
4.Tuberculosis. The most common form of tuberculosis. S/S is coughing of blood and chest pain (Carey, Higuera, & Nall, 2018).
- Panic disorder. Pt was anxious and was HR was 112. Pt stated that his heart felt like it was racing. S/S includes rapid breathing, chest pain, and sweating (Medline Plus, 2018).
P.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
Carey, E., Higuera, V., & Nall, R. (2018, March 28). Pulmonary Tuberculosis. Retrieved from Healthline: https://www.healthline.com/health/pulmonary-tuberculosis.
Chase, C., Leonard, M., & Gotter, A. (2017, March 17). Bacterial Pneumonia: Symptoms, Treatment, and Prevention. Retrieved from Healthline: https://www.healthline.com/health/bacterial-pneumonia.
Crosta, P. (2018, January 22). What’s to know about pulmonary embolism? Retrieved from Medical News Today: https://www.medicalnewstoday.com/articles/153796.php.
Jong, I. (2018, August 24). VQ Scan. Retrieved from Inside Radiology: https://www.insideradiology.com.au/vq-scan-hp/.
Medline Plus. (2011). Deep Vein Thrombosis: Symptoms, Diagnosis, Treatment and Latest NIH Research. Retrieved from National Institutes of Health: https://medlineplus.gov/magazine/issues/spring11/articles/spring11pg20-21.html.
Medline Plus. (2018, July 19). Panic Disorder. Retrieved from National Library of Medicine: https://medlineplus.gov/panicdisorder.html.
A Sample Answer 4 For the Assignment: NURS 6512 Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System
Title: NURS 6512 Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System
Patient Information:
- H, 54, Male, Caucasian
CC: “shortness of breath”
HPI: James Hendrix is a 54- year-old Caucasian male presents today with shortness of breath that began a few days ago and feeling fatigued all the time. He reports having difficulty breathing at rest that began a few days ago. This shortness of breath is characterized as occurring all the time. Associated signs and symptoms include a productive cough that lasts all night long, abdominal and leg swelling, and a 5 lbs. weight gain. Exacerbating factors include walking and the shortness of breath is worse at night, he is unable to lie in bed and sleeps in a recliner. Nothing relieves the shortness of breath.
Current Medications: Furosemide 20mg daily (not taken in the last 3 weeks) for edema, Lisinopril 20mg daily for hypertension, and Tamsulosin 0.4mg daily for BPH.
Allergies: No Known Drug Allergies
PMHx: Last tetanus shot was 8 years ago, all immunizations are current, received influenza vaccine 2 months ago. Hypertension, BPH, and total right knee arthroplasty (2015).
Soc Hx: Employed as a CPA, married for 30 years, 2 children in high school. Current smoker, 3 cigarettes a day, current alcohol use of 4 beers a week. Patient states always wears a seatbelt while in the car and does not text/ use his cell phone while driving.
Fam Hx: Father (84) living with CHF, hypertension, and cataracts. Mother (76) living with diabetes, hyperlipidemia and a history of breast cancer. Siblings and children are healthy.
ROS:
GENERAL: Confirms weight gain and fatigue, denies fever, chills, or weakness.
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 or palpitations. Confirms edema in the abdomen and legs.
RESPIRATORY: Confirms shortness of breath, a productive cough with clear sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: No burning or hesitancy with urination.
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.
Physical exam:
Vital signs: T 97.9 oral, RR 22 labored, HR 94, BP 162/90 right arm, O2 sat 92% room air, wt: 215 lbs.
General: Adult male with labored respirations
HEENT: The head is normocephalic, hair evenly distributed, PERRLA, EOMI, ear canals patent, bilateral TM pearly gray with positive light reflex, nasal mucosa pink and moist, no septal deviation, the pharynx is non-erythematous and clear, teeth are in good condition
Neurologic: A&Ox3
Cardiovascular: Heart rate is regular with good S1, S2; S3 auscultated with a 3/6 systolic murmur
Peripheral vascular: 3+ peripheral edema extending to bilateral knees; 2+ bilateral dorsalis pedis pulses
Respiratory: Thorax symmetrical, breath sounds vesicular with scattered rales throughout all lung fields, no ronchi or wheezes
Abdomen: Distended with normal bowel sounds auscultated in 4 quadrants
Skin: Cool and dry
Diagnostic results: Echo and TTE are pending. EKG shows sinus rhythm, chest x-ray show pleural effusions, CBC, CMP, cardiac enzymes, and d-dimer lab values are normal. BNP levels are elevated.
- A.
Differential Diagnoses
Priority Diagnosis: Congestive Heart Failure
- Congestive Heart Failure: Patients with CHF present with shortness of breath especially while lying down, fatigue and lethargy, abdominal and peripheral edema, abnormal lung sounds and a third heart beat (S3) can be auscultated. Diagnostic testing that confirms CHF include an elevated BNP and pulmonary congestion visualized on a chest x-ray (Inamdar & Inamdar, 2016).
- Chronic Obstructive Pulmonary Disease: Patients with COPD present with shortness of breath, a productive cough and a history of exposure to risk factors such as tobacco smoke. Additional symptoms may include fatigue (Global Initiative for Chronic Obstructive Lung Disease, 2016).
- Pulmonary Embolism: Patients with PEs present with shortness of breath, tachypnea, labored respirations, leg swelling, a cough, difficulty breathing lying flat, abnormal lung sounds, accentuated heart sounds and jugular vein distension (Morici, 2014).
- Pneumonia: Patients with CAP present with respiratory symptoms including a productive cough, difficulty breathing, chest pain, malaise, tachypnea, and abnormal lung sounds. A pneumonia diagnosis is confirmed with a chest x-ray indicating infiltrates as well as a sputum culture (Kolditz & Ewig, 2017).
- Pulmonary fibrosis: Patients with pulmonary fibrosis present with difficulty breathing, a cough and low oxygen saturation levels. Patients have adventitious breath sounds including fine crackles in the lower lung lobes. A chest CT will confirm a pulmonary fibrosis diagnosis (Nakamura & Suda, 2015).
References
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2016. Available from: https://goldcopd.org/
Inamdar, A., & Inamdar, A. (2016). Heart failure: diagnosis, management and utilization. Journal of clinical medicine, 5(7), 62. doi: 10.3390/jcm5070062
Kolditz, M., & Ewig, S. (2017). Community-acquired pneumonia in adults. Deutsches Ärzteblatt International, 114(49), 838. doi: 10.3238/arztebl.2017.0838
Morici, B. (2014). Diagnosis and management of acute pulmonary embolism. Journal of the American Academy of PAs, 27(4), 18-22. doi: 10.1097/01.JAA.0000444729.09046.09
Nakamura, Y., & Suda, T. (2015). Idiopathic pulmonary fibrosis: Diagnosis and clinical manifestations. Clinical Medicine Insights: Circulatory, Respiratory and Pulmonary Medicine, 9, CCRPM-S39897. doi: 10.4137/CCRPM.S39897
A Sample Answer 5 For the Assignment: NURS 6512 Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System
Title: NURS 6512 Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System
Patient Information:
Mr. Hendricks, 67, Male, Caucasian
CC: “I have a cough that’s getting worse, and it feels like I just can’t catchy my breath.”
HPI: Mr. Hendricks is a 67-year-old Caucasian male who presents to the clinic with complaints of a cough and shortness of breath. He developed the cough approximately 1 week ago but claims it is getting worse. He denies trying anything to improve his cough. Cough is strong and wet. He claims it is hard to bring secretions up with his cough but when he does, sputum is “thick and green in color with blood sometimes.” He started experiencing shortness of breath 2 days ago. He claims he is short of breath even in sitting position. Walking makes his shortness of breath worse and nothing makes it better. He does admit to taking Tylenol last night as he felt he was “coming down with a fever.” He admits to having difficulty falling asleep last night, and recently traveled to a family reunion 6 hours away. No other associated symptoms.
Current Medications:
1.) Tylenol 1000 mg PO q 6 hrs PRN for pain and fever
2.) Lisinopril 10mg PO once daily in am
3.) Atorvastatin 10mg PO once daily in am
4.) Multivitamin PO once daily in am
5.) Omeprazole 20mg PO once daily in am before breakfast
Allergies:
PCN – hives
Sulfa – angioedema
PMH
1.) HTN – controlled
2.) Hypercholesterolemia
3.) Obesity
4.) Gastroesophageal reflux (GERD) – controlled
PSH
1.) Vasectomy 1994
Sexual/Reproductive History:
Heterosexual
Vasectomy 1994
Social Hx:
Negative for current or past tobacco or illicit drug use. Drinks alcohol in moderation.
Immunization History
Tetanus: 2011
Influenza: None on record, previously declined
Pneumococcal pneumonia: None on record, previously declined
Family Hx:
Mother, deceased, age 71, breast cancer, hx HTN, hypothyroidism
Father, deceased, age 75, CVA, hx DM, HTN
Maternal Grandmother, deceased, age unknown, cancer – unknown, hx obesity
Maternal Grandfather, deceased, age unknown, MI, hx HTN
Paternal Grandmother, deceased, age unknown, unaware of medical hx
Paternal Grandfather, deceased, age unknown, lung cancer, unaware of additional medical hx
Brother, alive, 69, DM, CKD
Brother, alive, 63, HTN
Sister, deceased, age 43, motor vehicle accident, unaware of medical hx
Son, alive, 41, healthy, no known medical issues
Son, alive, 38, GERD, overweight
Daughter, alive, 36, hx depression, migraines
Daughter, alive, 33, healthy, no known medical issues
Lifestyle:
Patient is a retired schoolteacher. Married for 43 years with 4 adult children. Has support of wife and children. Diet is high in carbohydrates, consisting of three meals a day, mostly home cooked. Claims to recently been trying to make small changes to diet and exercise in hopes to improve cholesterol and reduce weight. Walks for 30 minutes in the evening 2-3 times per week now. Minimal stress in life; continues to volunteer at the school occasionally to keep active and involved in the community. Has Medicare insurance. Has seen primary care provider within past year.
ROS:
General: No weakness or night sweats. No recent weight gain or loss of significance. Admits to feeling feverish with chills, and fatigued.
HEENT: No history of head injury. Wears corrective lenses. Last eye examination within the past year. Denies visual changes, diplopia, floaters, or photophobia. Denies any hearing difficulties or loss of hearing. Denies tinnitus, vertigo, or infections. Occasional sinus drainage, seasonal. Denies any change in sense of smell. Denies any episodes of epistaxis, nasal polyps, or recent sinus infection. Denies bleeding gums; cavities that have been filled. Reports good oral care, last dental visit was 6 months ago. Denies difficulty chewing or swallowing.
Neck: Denies lumps, swollen glands, pain, or stiffness.
Breasts: Denies lumps or pain.
Respiratory: Cough for past week with green sputum, < 1/4 cup amount of sputum daily, blood present at times. Dyspnea for past 2 days. No night sweats. Denies pneumonia shot. No recent chest x-ray.
Cardiovascular: Hypertension. Hypercholesterolemia. Shortness of breath for past 2 days. Denies chest pain, pressure, palpitations, or orthopnea.
Gastrointestinal: No recent nausea, vomiting, diarrhea, or constipation. No melena or hematochezia. No pain, appetite is good. No known liver or gallbladder problems.
Genitourinary: No frequency, urgency, dysuria or hematuria. Denies incontinence, pain, or discharge. No prostate exam to date. No known hernia, masses.
Peripheral vascular: Denies varicose veins or edema. Denies leg pain or numbness or tingling in extremities.
Musculoskeletal: No musculoskeletal pain, joint swelling, arthritis. Denies recent falls.
Integumentary: No rash or itching. Denies dermatitis or psoriasis.
Psychiatric: Denies history of psychiatric disorders. No thoughts of self-harm. Denies depression and anxiety.
Neurologic: Denies headache, weakness, seizures, syncope, numbness/tingling in extremities. Denies changes in speech or memory.
Hematologic: Denies anemia, bleeding, bruising, or history of clotting disorders. No history of blood transfusion.
Endocrine: No night sweats, cold or heat intolerance, polyuria. No excessive thirst or hunger.
Allergic/Immunologic: Denies asthma, eczema, or rhinitis. No known immune deficiencies.
Physical Examination
Vital signs:
BP: 128/70, right arm, sitting; HR: 82, regular; RR: 20, labored; T: 100.9 degrees F, oral; SpO2: 89% RA; W: 210 pounds, stable; Ht: 5’7”; BMI: 32.9
General Appearance: Alert and oriented x3. Calm, cooperative, answers appropriately. Patient appears fatigued, skin color is pale, diaphoretic and feels a little warm to the touch. Appears to be in no acute distress. Well-groomed, appropriately dressed, overweight.
HEENT: Hair of average texture. Scalp without lesions, normocephalic/atraumatic. Conjunctiva pink; sclera white. Pupils equal, round, regular, reactive to light. Extraocular movements intact. Tympanic membranes visualized, clear canal and good cone of light, bilaterally. Acuity good to whispered voice. Mucosa pink, septum midline. Oral mucosa pink. Good dentition. Tongue midline, pink, and moist. Tonsils absent. Pharynx without exudates.
Neck: Trachea midline, supple, no palpable nodes
Lymph nodes: No lymphadenopathy in any nodes. No palpable cervical, axillary or epitrochlear nodes. Small inguinal nodes bilaterally, soft and nontender.
Chest: Heart rate regular with normal S1, S2; no S3, S4. No murmurs, rubs, and gallops.
Lungs: Lung expansion symmetrical. Diminished lung sounds with rales and expiratory wheezes throughout, no rhonchi. Respiratory rate regular, no use of accessary muscles. Wet, productive cough noted.
Abdomen: Soft, protuberant, non-tender. No organomegaly or masses. Normoactive bowel sounds auscultated x4 quadrants.
Extremities: No clubbing, cyanosis edema, or bruising. Calves non-tender.
Peripheral vascular: No pedal edema; 2+ dorsalis pedis pulses bilaterally, capillary refill less than 3 seconds.
Musculoskeletal: No deformities orenlarged joints. Normal range of motion (ROM), good muscle tone and strength.
Neurologic Mental Status: Awake, alert and oriented to person, place, and time. Cooperative. Normal sensation in lower legs and feet, normal refluxes, stable gait. No slurred speech. No deficits noted.
Skin: Warm, moist, pale. Intact without lesions, rashes, or urticaria.
Diagnostics:
1.) PA and lateral chest x-ray
2.) Gram stain and sputum culture specimen
3.) CBC with differential
(Hollier & Hensley, 2011).
4.) ABGs or VBGs
(Dains, Bauman, & Scheibel, 2016).
5.) D-dimer – rule out pulmonary embolism
(Dains, Bauman, & Scheibel, 2016).
Diagnosis of pneumonia is based on clinical presentation and chest x-ray. Presence of infiltrates is considered the gold standard in the diagnosis of pneumonia (Hollier & Hensley, 2011).
Assessment:
DDx:
1.) Pneumonia (primary dx)
Pneumonia is the primary diagnosis for this patient. He is at increased risk due to his age, history of GERD, noncompliance of receiving annual influenza vaccination and pneumonia vaccination, and recent encounter with many people at the family reunion he recently attended. Patient has been experiencing a productive cough that is green in color with some blood noted, and dyspnea (Dains, Bauman, & Scheibel, 2016). He is also experiencing a fever >100.4 degrees F and chills (Hollier & Hensley, 2011).
2.) Pulmonary embolism
Pulmonary embolism is a differential diagnosis to consider as this patient complains of dyspnea at rest, which started 2 days ago. He has been experiencing a cough for one week. Sputum produced from cough occasionally brings up blood. Patient recently experienced prolonged sitting as he traveled 6 hours away for a family reunion (Rhoads & Jensen, 2015).
3.) Heart failure
Heart failure is a differential diagnosis to consider as this patient complains of dyspnea at rest that worsens with exertion, and a productive cough. Lung sounds reveals rales. He is also at increased risk due to his history of hypertension (Hollier & Hensley, 2011).
4.) Asthma
Asthma is a differential diagnosis to consider as this patient presents with dyspnea and a cough. Lung sounds reveal diminished breath sounds with expiratory wheezes (Dains, Bauman, & Scheibel, 2016). He is dyspneic at rest and this worsens with activity. He is also at increased risk for asthma due to his GERD and obesity (Hollier & Hensley, 2011).
5.) Acute Bronchitis
Acute bronchitis is a differential diagnosis to consider at this patient presents with a productive cough and fever. Lung sounds reveal wheezes. He is at increased risk for acute bronchitis due to his age and recent encounter with many family members during his family reunion (Hollier & Hensley, 2011).
References
Dains, J., Bauman, L., Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in
primary care (5th ed.). St. Louis: Missouri: Elsevier.
Hollier, A., & Hensley, R. (2011). Clinical Guidelines in Primary Care: A Reference and Review
Book. Layfayette, LA: Advanced Practice Education Associated, Inc.
Rhoads, J. & Jensen, M. (2015). Cough. In J. Rhoads & M. Jensen (Eds.). Differential diagnosis
for the advanced practice nurse. (pp. 37-47). New York, NY: Springer Publishing Company.
A Sample Answer 6 For the Assignment: NURS 6512 Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System
Title: NURS 6512 Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System
CC: Shortness of Breath (SOB)
HPI: Mr. Hendrix’s (Mr. H), a Caucasian male who developed SOB three days ago. Mr. H, state’s he is SOB all the time, with an increased effort of breathing with activity and lying down. Mr. H states due to the shortness of breath he sleeps in a recliner. Mr. H states he has gain 5 pounds since his last visit. He also complains of swelling of his lower legs and a cough. Mr. H states he smokes but has recently cut back to three cigarettes a day but, is trying to quit.
PMH: Fluid retention and Lasix for relief, need more information
FH: No family history reported but it would be important to know.
SH: Tobacco use for years.
ROS
General- Shortness of breath
Cardiovascular- positive for orthopnea, positive for edema of the abdomen and lower extremity.
Gastrointestinal- Negative for nausea, vomiting, and diarrhea.
Pulmonary- Positive cough, dyspnea with activity.
O.
VS: 162/90; P 94; R 22; T 97.9 oral; O2 Sat 92%; Wt 215
General- Mr. H, is anxious and SOB
Cardiovascular- Skin is cool and dry, Heart rate is regular S1, S2 heard. Third heart sound noted at apex Grade 3/6 systolic murmur. Negative for cyanosis, positive 3+ LE edema extends to knees bilaterally. Positive dorsalis pedal pulses bilaterally.
Gastrointestinal- Abdomen is distended, normoactive bowel sounds in all four quadrants.
Pulmonary- Respiration labored, rate 22. Thorax symmetrical, vesicular breath sounds and scattered rails throughout, no rhonchi or wheezes.
Diagnostic results:
1: Blood test to look at the health of the kidneys and thyroid gland. Additionally, to assess the patient cholesterol level and to check for anemia.
2: B-type natriuretic peptide (BNP) blood test is a substance released when heart failure develops. Levels are higher in people with heart failure.
3: Chest X-ray to show the size of Mr. H heart and buildup of fluid around the heart and lungs.
4: Echocardiogram to look at the movement of the heart, take pictures of the heart valves, chambers, and get an estimation of how well the heart squeezes called the ejection fracture (EF).
5: Lasix for fluid removal
Differential Diagnosis:
Respiratory Failure, Acute respiratory distress syndrome often has to be differentiated from congestive heart failure, which usually has signs of fluid overload, and from pneumonia. Treatment of acute respiratory distress syndrome is supportive and includes mechanical ventilation, prophylaxis for stress ulcers and venous thromboembolism, nutritional support, and treatment of the underlying injury (Saguil and Fargo. 2012).
Cardiogenic Pulmonary Edema, the initial management of patients with cardiogenic pulmonary edema (CPE) should address the ABCs of resuscitation, that is, airway, breathing, and circulation. Oxygen should be administered to all patients to keep oxygen saturation at greater than 90%. Any associated arrhythmia or MI should be treated appropriately.
Methods of oxygen delivery include the use of a face mask, noninvasive pressure-support ventilation (which includes bilevel positive airway pressure [BiPAP] and continuous positive airway pressure [CPAP]), and intubation and mechanical ventilation (Sovari, Ool, 2017).
Pulmonary Embolism, The most dreaded acute complication of PE is death; it is estimated that over 100,000 deaths in hospitalized patients in the United States are attributable to acute PE each year.4 The severity of PE is stratified into massive (PE causing hemodynamic compromise), submissive (PE causing right ventricular dysfunction demonstrable by echocardiography, computed tomography or elevated cardiac biomarkers (Aggarwal, Nicolais, Lee, & Bashir, 2017).
Chronic Obstructive Pulmonary Disease, Chronic obstructive pulmonary disease (COPD) exacerbations are a very common reason for admission to hospital. Approximately 20% of patients hospitalized for COPD present with or develop hypercapnic respiratory failure which is an indicator of an increased risk of death (Rochwerg, Brochard, Elliott, Hess, Hill, Nava, and Navalesi, 2017)
Venous Insufficiency, there is general agreement between all guidelines that clinical manifestation consistent with superficial venous insufficiency needs to be documented. A thorough medical history should be performed to identify symptoms potentially related to superficial venous insufficiency (Passman, 2015).
Primary Diagnosis/Presumptive Diagnosis: Heart Failure
Based on Diagnostic findings, the patient should be placed on angiotensin receptor blockers, Diuretics, Hydralazine plus nitrate, and Digoxin, Education on new condition, F/U regularly with Cardiologist and monitoring for adverse effects of medication and placed on a 1 to 1.5-liter fluid restriction.
References:
Rochwerg, B., Brochard, L., Elliott, M. W., Hess, D., Hill, N. S., Nava, S. Navalesi, P. (2017). Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure; https://www.thoracic.org/statements/resources/cc/niv-guidelines.pdf
Aggarwal, V., Nicolais, C. D., Lee, A., Bashir, R. (2017). Acute Management of Pulmonary Embolism; https://www.acc.org/latest-in-cardiology/articles/2017/10/23/12/12/acute-management-of-pulmonary-embolism
Sovari, A. A., Ool, H. H. (2017) Cardiogenic Pulmonary Edema Treatment & Management; https://emedicine.medscape.com/article/157452-treatment
Saguil, A., Fargo, M. Acute Respiratory Distress Syndrome Diagnosis and Management: https://www.aafp.org/afp/2012/0215/p352.html
Passman, M. A. (2015). Evidence-Based Treatment of Superficial Venous Insufficiency: https://www.veindirectory.org/magazine/article/techniques-technology/evidence-based-treatment-of-superficial-venous-insufficiency
A Sample Answer 7 For the Assignment: NURS 6512 Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System
Title: NURS 6512 Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System
Patient Information:
Initials: SA Age: 65 Sex: Male Race: African American
S.
CC: “Shortness of breath of breath all the time, even when talking”
HPI: This is a 52 years old African American male who came to the clinic due to shortness of breath that is interfering with his daily activities. The patient has a history of hypertension and hyperlipidemia. The patient experience shortness of breath when speaking and walking for the past week. The patient reported difficulty with sleeping, due to shortness of breath and coughing. The patient stated that a cough is worse at nights, and is non- stop, clear phlegm is produced from the coughing. The patient stated that due to the severity of a cough at nights he must sleep in a recliner. The patient stated that nothing seems to help relieve his shortness of breath. The patient that within the past week he gained 5 pounds, despite no changes in his eating habits. The stated that his pants were now fitting more tightly. The patient is experiencing swelling in the abdomen and legs. The patient denies any chest pain and chest discomfort. The reported being noncompliant with his water medication that was prescribed because it caused him to urinate frequently.
Current Medications: Spironolactone 100 mg po daily for 5 years for hypertension, Simvastatin 40 mg po daily for high cholesterol for 6 months, multivitamin one tablet daily, for the past 5 years for a vitamin supplement.
Allergies: Shrimp – Swelling of the throat, Penicillin – Hives and Rashes
PMHx: updated on annual flu and pneumococcal vaccination, childhood chickenpox.
Soc Hx: Retired chief, who enjoys fishing and listen to music, jogging and playing with grandchildren. A former pack day cigarette smoker. Drinks alcohol socially. Married for the past 40 yrs. with three children age, 29, 33, and 38 and two grandkids who are 3 and 7. The patient reports wearing his seatbelt always and avoid using electronics while operating a vehicle.
Fam Hx: Family history of hypertension and diabetes on both maternal and paternal side of the family. One brother 63 who suffers from hypertension and diabetes, one sister 57 who has hypertension and pre-diabetic. Grandmother passed away from health failure at 89 years, great grandfather passed away from complications for diabetes and cancer in the stomach at age 67. Children are healthy with no current medical conditions. Grandchildren suffer from seasonal allergies
ROS:
GENERAL: Patient-reported shortness of breath, weight gain, fatigue and tiredness related to lack of sleep from coughing, with phlegm that is clear. Denies fever and chills.
HEENT: no swelling, scalp free of cuts flakes,
EYES: denies any difficulties with vision, sees clearly,
EARS: no issues with hearing,
NOSE: no nasal drainage,
THROAT: coughing reported that is more intense in the nights, denies a sore throat, denies difficulties with swallowing.
SKIN: Intact, cool and dry, no rash and hives
CARDIOVASCULAR: Denies chest pain and discomfort, Heart rate is regular with good S1, S2; S3 auscultated, with a 3/6 systolic murmur
RESPIRATORY: labored respiration, difficulties with breathing, coughing, clear mucus
GASTROINTESTINAL: Swelling in the abdomen, denies nausea, upset stomach, and nausea, denies any bowel movement abnormalities.
GENITOURINARY: Urinary urgency when on water pills, denies any difficulties with voiding, no dribbling, and burning sensation.
NEUROLOGICAL: denies any pain and numbness in all extremities, denies any headaches, lightheadedness, no issues with bowel movements and with urination
MUSCULOSKELETAL: Swelling in bilateral legs up to knees that are 3+, denies any problems with range of motions, able to move all extremities without any pain.
HEMATOLOGIC: No issues with bruising easily, no abnormal bleeding.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies any issues with mental illness
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
PE: Weight :215, Temperature: 97.9 oral, Respiratory rate: 22, Heart rate: 94, BP 162/90, Oxygen saturation: 92% on room air
Physical exam:
General: SA is a 67 years old African American male who is alert, awake and oriented x 4. Appropriately groomed for the weather and season, well nourished, and well developed. Able to speak in complete sentences, difficulties with breathing, weight gain, swelling in the abdomen and bilaterally lower extremities.
HEENT: Head normocephalic. Hair thick and evenly distributed throughout the scalp. No dryness, lesions, scars, redness or swelling.
Eyes: conjunctiva clear, sclera non-icteric, PERRLA, EOMs intact. No exudates or hemorrhages
Ears: Tympanic membranes pearly gray and intact, no drainage, light reflex noted. Pinna and tragus non-tender. Hearing intact
Nose: Nares patent without exudate. Mucosa pink and moist. Nasal septum midline without deviation. Sinuses non-tender to palpation. No external lesions or drainage.
Throat: Oropharynx pink and moist without lesions or exudate. No obvious caries or periodontal disease. Teeth in good condition, no cavities noted. Tongue midline, smooth, pink without lesions.
Neck: supple, no cervical lymphadenopathy or tenderness noted. Thyroid midline, small, non-enlarged and non-tender. No JVD present.
CV: good S1, S2; S3 auscultated, with a 3/6 systolic murmur
Lungs: Thorax symmetrical; breath sounds vesicular with scattered rales throughout all lung fields; no rhonchi or wheezes
Gastrointestinal: Distended with normoactive bowel sounds auscultated x4 quadrants
Skin: cool, dry and intact
Peripheral vascular: 3+ peripheral edema extending to knees bilaterally; 2+ dorsalis pedis pulses bilaterally
Neurologic: Awake, alert, and oriented to person, place, time and day.
Careful assessment must be done seeing that several conditions can be responsible for the patient’s shortness of breath, swelling in the abdomen and lower extremities. The patients have hypertension and hyperlipidemia that can lead to other disorders. Some possible diagnoses are; venous insufficiency, kidney disease, low protein in blood, liver diseases, lung conditions, (emphysema, COPD) and lymphedema (Institute for Quality and Efficiency Healthcare, 2016).
Testing/Diagnostics
According to (Shea and Thompson, 2018) for most people with widespread swelling, blood tests are done to evaluate the function of the heart, kidneys, and liver. Urinalysis is usually also done to check for large amounts of protein, which can indicate nephrotic syndrome or, in pregnant women, preeclampsia. Other tests are done based on the suspected cause. For example, in people with isolated leg swelling, doctors may do ultrasonography to look for blockage of a vein in the leg. A chest x-ray can show an enlarged heart, and congested blood vessels and fluid accumulation in the lungs (Shah, 2018). Electrocardiography (ECG) is almost always done to determine whether the heart rhythm is normal, whether the walls of the ventricles are thickened, and whether the person has had a heart attack (Shah, 2018). Echocardiography which uses sound waves to produce an image of the heart is one of the best procedures for evaluating heart function, including the pumping ability of the heart and the functioning of heart valves (Shah, 2018).
- A.
Differential Diagnoses
Heart Failure
This disorder tends to occur when the contracting action or the relaxing action of the heart is inadequate, typically because the heart muscle is weak, stiff, or both (Shah, 2018). Many disorders that affect the heart can cause heart failure. Most people have no symptoms at first, and just shortness of breath and fatigue develop gradually over days to months. Fluid may accumulate in the lungs, abdomen, or legs (Shah, 2018). This was the cause in SA in the case study he was experience shortness of breath, fatigue walking and talking, fluid retention in the lower extremities and abdomen. There is also the risk factor of hypertension. According to (Shah, 2018) hypertension and obesity can contribute to both left and right-side heart failure. The heart -failure that SA might be experiencing is left the side, since those who suffer from this side of failure, tend to have worsened shortness of breath of nights because when they are lying down gravity causes more fluid to move into the lungs. Such people often wake up, gasping for breath or wheezing (a condition called paroxysmal nocturnal dyspnea). Sitting up causes some of the fluid to drain to the bottom of the lungs and makes breathing easier (Shah, 2018). People with left-sided heart failure also feel tired and weak when doing physical activities, because their muscles are not receiving enough blood (Shah, 2018).
Pulmonary Embolism
Occurs whenever a pulmonary artery is blocked by an embolus, people may not be able to get sufficient oxygen into the blood. This in turn to leads to shortness of breath (Tapson, 2018). Some risks for this disorder are; obesity, smoking, among others (Tapson, 2018). This was the case with SA he was overweight and was a former smoker.
Nephrotic Syndrome
This disorder occurs due to excessive excretion of protein, this results in low levels of important proteins, such as albumin, in the blood (Jaipaul, 2018). People also have increased levels of fats (lipids) in the blood, a tendency to increased blood clotting, and greater susceptibility to infection (Jaipaul, 2018) this could be the case with SA in the case study because he has hyperlipemia. The decreased level of albumin in the blood causes fluid to leave the bloodstream and enter the tissues. Fluid in the tissues leads to edema. Fluid leaving the bloodstream causes the kidneys to compensate by retaining more sodium. The most common disorders causing nephrotic syndrome are diabetes and lupus, while SA does not have diabetes, there is a strong family history diabetes. The abdomen may be swollen because of a large accumulation of fluid in the abdominal cavity (ascites). Shortness of breath may develop because fluid accumulates in the space surrounding the lungs (Jaipaul, 2018).
Chronic Obstructive Pulmonary Disease
Cigarette smoking is the most important cause of chronic obstructive pulmonary disease (Wise, 2018). SA is a former pack a day cigarette smoker. People develop a cough and eventually become short of breath. In people with COPD, a mild cough that produces clear sputum develops during their 40s or 50s (Wise, 2018). A cough and sputum production are usually worse when the person first gets out of bed in the morning. A cough and sputum production can persist throughout the day (Wise, 2018). Shortness of breath may occur during exertion.
Lymphedema
Occurs when lymphatic vessels are injured or obstructed, lymph fluid cannot drain and accumulates in tissues, causing swelling (Douketis, 2017). The swelling starts gradually in one or both legs. The first sign of lymphedema may be puffiness of the foot, making the shoe feel tight at the end of the day (Douketis, 2017).
References
Douketis, D. J. (2017). Lymphedema. Retrieved from https://www.merckmanuals.com/home/heart-and-
blood-vessel-disorders/lymphatic-disorders/lymphedema
Institute for Quality and Efficiency in Health Care (2016)-. Causes and signs of edema.
Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK279409/
Jaipaul, N (2018). Nephrotic syndrome. Retrieved from
https://www.merckmanuals.com/home/kidney-and-urinary-tract-disorders/kidney
filtering-disorders/nephrotic-syndrome#v761896
Shah, J.S. (2018). Heart Failure. Retrieved from
https://www.merckmanuals.com/home/heart-and-blood-vessel-disorders/heart-failure/heart-failure
Shea, J.M. and Thompson, D. A (2018). Swelling edema. Retrieved from
https://www.merckmanuals.com/home/heart-and-blood-vessel-disorders/symptoms-of-
heart-and-blood-vessel-disorders/swelling
Tapson F. V. (2018). Pulmonary embolism. Retrieved from
https://www.merckmanuals.com/home/lung-and-airway-disorders/pulmonary-
embolism/pulmonary-embolism-pe
Wise, A. R (2018), Chronic obstructive pulmonary disease. Retrieved from