​Assignment 1: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System

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 Assignment, you will conduct a focused exam related to chest pain using the given senerio simulation too, . 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?

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Case Study: Brian a 58 years old caucasion man , Says “I have been having some troubling chest pain now and then for past moth” The pain is At center of chest and not rotating anywhere else. Started when I was working at the yard. It is worse when I am doing activities and it gets settled when I sit . Pain score 5/10. Not taken anything for it. No SOB, Nausea or vomiting, last BM was this morning. No surgeries or ever been hospitalized.

wt-197 ibs, Ht 5’11’ Home medications Lisinopril 20ng dail, Atrovastatin (Liptor)20 mg PO Q bedtime,last dose 10pm yesterday(hyperlipedemia),Omega-3 Fish Oil 1200 mg PO BID last dose 8 am (OTC suplement)

Allergies-Codeine: nausea and Vomiting

Immunizations: .. T dap 10/2014 and Influenza vaccine this season

Medical History:: Hypertensiob-stage 11, diagnozed 1 year ago and Hyperlipidemia –diagnose 1 year ago… No Surgical History

Family History. Father Hypertension, Hyperlipedemia, Obesity. Died of colon cancer age75. Mother : type 2 diabetic, Hypertension age 80 living. Other died age 24in MVA. Sister: Type 2 diabetes, Hypertension age 52 Living. Maternal Grand ma: Died of breast cancer age 65. Maternal grand pa:Died of heart attck age 54 . Paternal grandma: died of pneumonia age 78. Paternal Grandpa Died of “old age” age 85 : His Son is age 25 healthy His Daughter age 19 has asthma.

Social History:No past or present tobacco-use. Reports drinking 2-3 alcoholic beverages(beer) per week. Denies use of marijuana, cocaine, heroin or other illicit drugs

He is not retired. He works as an engineer. lives with the wife and daughter in a great neighborhood.

 

 

 

 

NB

  • 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?

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Focused Exam: Chest Pain

 

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RUBRICs

Subjective Documentation in Provider Notes

 

Subjective narrative documentation in Provider Notes is detailed and organized and includes:

 

Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)

 

ROS: covers all body systems that may help you formulate a list of differential diagnoses. 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.

Points Range: 16 (16%) – 20 (20%)

Documentation is detailed and organized with all pertinent information noted in professional language.

 

Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

 

Points Range: 11 (11%) – 15 (15%)

Documentation with sufficient details, some organization and some pertinent information noted in professional language.

 

Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

 

Points Range: 6 (6%) – 10 (10%)

Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language.

 

Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

 

Points Range: 0 (0%) – 5 (5%)

Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language.

 

No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

 

or

 

No documentation provided.

Objective Documentation in Provider Notes – this is to be completed in Shadow Health

 

Physical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”.

 

You only need to examine the systems that are pertinent to the CC, HPI, and History.

 

Diagnostic result – Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned

 

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

Points Range: 16 (16%) – 20 (20%)

Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language.

 

Each system assessed is clearly documented with measurable details of the exam.

 

Points Range: 11 (11%) – 15 (15%)

Documentation with sufficient details and some organization; some abnormal and some normal assessment information described in mostly professional language.

 

Each system assessed is somewhat clearly documented with measurable details of the exam.

 

Points Range: 6 (6%) – 10 (10%)

Documentation with inadequate details and/or organization; inadequate identification of abnormal and pertinent normal assessment information described; inadequate use of professional language.

 

Each system assessed is minimally or is not clearly documented with measurable details of the exam.

 

Points Range: 0 (0%) – 5 (5%)

Documentation with no details and/or organization; no identification of abnormal and pertinent normal assessment information described; no use of professional language.

 

None of the systems are assessed, no documentation of details of the exam.

 

or

 

No documentation provided.

 

 

Use This Tablet please: 

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:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

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

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies 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.

P.  

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 7th edition formatting.

 

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