Assignment: Assessing the Heart Lungs and Peripheral Vascular System

Assignment: Assessing the Heart Lungs and Peripheral Vascular System

Assignment: Assessing the Heart Lungs and Peripheral Vascular System

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 fivepossible 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.

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Comprehensive SOAP Exemplar

Purpose: To demonstrate what each section of the SOAP Note should include. Remember that nurse practitioners treat patients in a holistic manner, and your SOAP Note should reflect that premise.

 

Patient Initials: _______               Age: _______                             Gender: _______

 

SUBJECTIVE DATA:

 

Chief Complaint (CC): Coughing up phlegm and fever

 

History of Present Illness (HPI): Sara Jones is a 65-year-old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last 3 days. She reported that the “cold feels like it is descending into her chest.” The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4 last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but it returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10.

 

Medications:

• Lisinopril 10mg daily
• Combivent 2 puffs every 6 hours as needed
• Serovent daily
• Salmeterol daily
• Over-the-counter Ibuprofen 200mg -2 PO as needed
• Over-the-counter Benefiber
• Flonase 1 spray each night as needed for allergic rhinitis symptoms

 

Allergies:

Sulfa drugs – rash

 

Past Medical History (PMH):

1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and hand held nebulizer treatments.

2.) Hypertension – well controlled

3.) Gastroesophageal reflux (GERD) – quiet, on no medication

4.) Osteopenia

5.) Allergic rhinitis

 

Past Surgical History (PSH):

• Cholecystectomy 1994
• Total abdominal hysterectomy (TAH) 1998

 

Sexual/Reproductive History:

Heterosexual

G1P1A0

Non-menstruating – TAH 1998

 

Personal/Social History:

She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use.

 

Immunization History:

Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time.

 

Significant Family History:

Two brothers – one with diabetes, dx at age 65, and the other with prostate CA, dx at age 62. She has one daughter in her 30s, healthy, living in nearby neighborhood.

 

Lifestyle:

She is retired, has been widowed x 8 years, and lives in the city in a moderate crime area with good public transportation. She is a college graduate, owns her home, and receives a pension of $50,000 annually – financially stable.

 

She has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. She has medical insurance but often asks for drug samples for cost savings. She has a healthy diet and eating pattern. There are resources and community groups in her area at the senior center that she attends regularly. She enjoys bingo. She has a good support system composed of family and friends.

Assignment: Assessing the Heart Lungs and Peripheral Vascular System 

Review of Systems:

 

General: + fatigue since the illness started; + fever, no chills or night sweats; no recent weight gains of losses of significance

 

HEENT: No changes in vision or hearing; she does wear glasses, and her last eye exam was 1 ½ years ago. She reported no history of glaucoma, diplopia, floaters, excessive tearing, or photophobia. She does have bilateral small cataracts that are being followed by her ophthalmologist. She has had no recent ear infections, tinnitus, or discharge from the ears. She reported her sense of smell is intact. She has not had any episodes of epistaxis. She does not have a history of nasal polyps or recent sinus infection. She has a history of allergic rhinitis that is seasonal. Her last dental exam was 3/2014. She denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. She has had no difficulty chewing or swallowing.

 

Neck: No pain, injury, or history of disc disease or compression. Her last Bone Mineral density (BMD) test was 2013 and showed mild osteopenia, she said.

 

Breasts: No reports of breast changes. No history of lesions, masses, or rashes. No history of abnormal mammograms.

 

Respiratory: + cough and sputum production (see HPI); denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; she has history of COPD and community acquired pneumonia 2012. Last PPD was 2013. Last CXR – 1 month ago.

 

CV: No chest discomfort, palpitations, history of murmur; no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication. Date of last ECG/cardiac work up is unknown by patient.

 

GI: No nausea or vomiting, reflux controlled. No abd pain, no changes in bowel/bladder pattern. She uses fiber as a daily laxative to prevent constipation.

 

GU: No change in her urinary pattern, dysuria, or incontinence. She is heterosexual. She has had a total abd hysterectomy. No history of STDs or HPV. She has not been sexually active since the death of her husband.

 

MS: She has no arthralgia/myalgia, no arthritis, gout or limitation in her range of motion by report. No history of trauma or fractures.

 

Psych: No history of anxiety or depression. No sleep disturbance, delusions, or mental health history. She denied suicidal/homicidal history.

 

Neuro: No syncopal episodes or dizziness, no paresthesia, headaches. No change in memory or thinking patterns; no twitches or abnormal movements; no history of gait disturbance or problems with coordination. No falls or seizure history.

 

Integument/Heme/Lymph: No rashes, itching, or bruising. She uses lotion to prevent dry skin. She has no history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties, or history of transfusions.

 

Endocrine: No endocrine symptoms or hormone therapies.

 

Allergic/Immunologic: Has hx of allergic rhinitis, but no known immune deficiencies. Her last HIV test was 10 years ago.

 

OBJECTIVE DATA

Physical Exam:

Vital signs: B/P 110/72, left arm, sitting, regular cuff; P 70 and regular; T 98.3 orally; RR 16; non-labored; Wt: 115 lbs; Ht: 5’2; BMI 21

General: A&O x3, NAD, appears mildly uncomfortable

HEENT: PERRLA, EOMI, oronasopharynx is clear

Neck: Carotids no bruit, jvd or tmegally

Chest/Lungs: CTA AP&L

Heart/Peripheral Vascular: RRR without murmur, rub, or gallop; pulses+2 bilat pedal and +2 radial

ABD: benign, nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound

Genital/Rectal: external genitalia intact, no cervical motion tenderness, no adnexal masses.

Musculoskeletal: symmetric muscle development – some age-related atrophy; muscle strengths 5/5 all groups

Neuro: CN II – XII grossly intact, DTR’s intact

Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes

 

ASSESSMENT:

Lab Tests and Results:

CBC – WBC 15,000 with + left shift

SAO2 – 98%

 

Diagnostics:

Lab:

Radiology:

CXR – cardiomegaly with air trapping and increased AP diameter

ECG

Normal sinus rhythm

 

Differential Diagnosis (DDx):

• Acute Bronchitis
• Pulmonary Embolis
• Lung Cancer

 

Diagnoses/Client Problems:

 

1.) COPD

2.) HTN, controlled

3.) Tobacco abuse – 40-pack-a-year history

4.) Allergy to sulfa drugs – rash

5.) GERD – quiet, on no current medication

 

PLAN: [This section is not required for the assignments in this course but will be required for future courses.]

Assignment: Assessing the Heart Lungs and Peripheral Vascular System

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EXAMPLE SOAP NOTE

Example Focused SOAP Note for a patient with chest pain S. CC: “Chest pain” HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning.  The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms. PMH: Positive history of GERD and hypertension is controlled FH: Mother died at 78 of breast cancer; Father at 75 of CVA.  No history of premature cardiovascular disease in first degree relatives. SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years ROS General–Negative for fevers, chills, fatigue Cardiovascular–Negative for orthopnea, PND, positive for intermittent lower extremity edema Gastrointestinal–Positive for nausea without vomiting; negative for diarrhea, abdominal pain Pulmonary–Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis   O. VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”   General–Pt appears diaphoretic and anxious Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the second right inter-costal space which radiates to the neck. A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted. Gastrointestinal–The abdomen is symmetrical without distention; bowel sounds are normal in quality and intensity in all areas; a bruit is heard in the right para-umbilical area. No masses or splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation. Pulmonary— Lungs are clear to auscultation and percussion bilaterally   Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines)   A. Differential Diagnosis: 1) Myocardial Infarction (provide supportive documentation with evidence based guidelines). 2) Angina (provide supportive documentation with evidence based guidelines). 3) Costochondritis (provide supportive documentation with evidence based guidelines).     Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction

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