Assignment 1: Digital Clinical Experience: Assessing the Heart Lungs and Peripheral Vascular System NURS 6512N-32

Week 7
Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation

SUBJECTIVE DATA:
Chief Complaint (CC): “I have been having some troubling chest pain in my chest for some time now.”
History of Present Illness (HPI): A 58-year-old Caucasian male comes to the clinic. The patient reports, “I have been having some troubling chest pain in my chest for some time now.” The patient further reports that he has been having chest pains periodically, particularly when exerting himself in the yard or while overeating. The location of the pain is at the mid sternum region, and he scores it as a 5/10 whenever he experiences it. His description of the pain is “tight and uncomfortable.” The pain does not radiate. The pain does not last for long and disappears upon the patient’s resting. His latest chest pain episode occurred three days ago at a restaurant due to a large dinner. He did not think the pain required urgent attention; however, he demonstrates concern due to the three episodes within the month, and, as such, he needs the heart to be examined. He also states that his legs cramp mildly when engaged in inactivity. He rejects the presence of dyspnea, GERD, indigestion, and heartburn. He states there is no chest pain at the time of assessment.

Medications: The patient has a medical history of using omega three on a daily basis from fish oil, atorvastatin (20 mg) on a daily basis, for high cholesterol for the last one year, occasional use of ibuprofen. The patient takes metoprolol, 100 mg for high blood pressure.

Allergies: The patient confirms some allergies

Past Medical History (PMH): The patient last visited a primary care provider last three months ago. The patient has had treatments for high cholesterol and high blood pressure but reports no incidences of hospitalization.

Past Surgical History (PSH): no past surgical history was reported

Personal/Social History: while the patient denies using tobacco, he agrees that he consumes alcohol moderately, with the patient using two to three alcoholic drinks every week. The patient does not engage in any regular exercise in recent times as the last regular exercise was done the last time two years ago.

Immunization History: No immunization data was presented.

Significant Family History: The late father had obesity, hypertension, and hyperlipidemia, sister has diabetes type 2 and hypertension. Mother had a heart attack.

Review of Systems
General: The patient reports a recent weight gain since the loss of his bike. Denies any sweats, night sweats, chills, fever, and fatigue
Cardiovascular/Peripheral Vascular: no edema, orthopnea, nor chest pain
Respiratory: no pneumonia, dyspnea, hemoptysis, wheezing, and cough
Gastrointestinal: denies ulcers, eating disorders, hepatitis, constipation or
abdominal pain
Musculoskeletal: no fracture, pain or stiffness, joint swelling or back pain
Psychiatric: No suicidal attempts/ideation, sleeping difficulties, anxiety or
depression

OBJECTIVE DATA:
Physical Exam:
Vital signs: BP : 105/78; T: 98.3; P: 117; R:22; Weight: 124lbs; Height: Height 5’
General Survey: The patient is a 58-year-old who demonstrates alertness and is proper orientation. He has clear speech and does not appear to be in any acute distress.
Cardiac: S1, S2, gallops do not have rubs or murmurs. The PMI has a lateral displacement. S3 is appearing at the mitral area.
Peripheral Vascular: He has a carotid bruit on the right side. His JVP appears above the sternal angle at 3cm. He has 3+ thrill at the right carotid. The pulse in the left carotid lacks thrill and has a 2+ expected amplitude. The femoral, radial, and brachial pulses lacked bruit ar 2+. Dorsalis pedis, tibial and popliteal pulses lack thrill at 1+. The capillary refill occurs below 3 seconds at all the four extremities.
Respiratory: The patient breathes quietly and unlabored. His breath sounds showed clarity to auscultation around the RML and the upper lobes. The patient produces fine rales/crackles in the bases of posterior regions of the left and right lungs.
Gastrointestinal: The abdomen is soft, round with a non-tender appearance. All four quadrants produce normoactive sounds. The abdomen lacks bruits. Both palpitations did not show tenderness. Tympany exists throughout the abdomen. The patient’s liver’s length is 7cm and 1 cm at the MCL and below the right costal margin, respectively. The bilateral kidneys and the spleen lack palpability.
Neuro: The patient is oriented everywhere and alert. He does not disobey commands. All of his extremities move when instructed.
Skin: The skin is intact, pink, and dry. It does not have tenting.
EKG: The interpretation of the EKG shows regular sinus rhythm. There are no changes in the ST as well. .
Diagnostics
The patient should undergo an X-ray examination of the chest (Ball et al., 2017). He should also have a fasting lab workup that includes liver function, BNP, CBC, Hgb A1C, electrolytes, cardiac enzymes, and lipid profile tests. These tests can be instrumental in confirming the exact illness troubling Mr. Foster.
ASSESSMENT
Priority diagnosis: Coronary artery disease with stable angina

Congestive heart failure
Carotid artery disease

GERD

Coronary artery disease: The patient’s angina or chest pain could be resulting from plaque buildup in the arteries responsible for supplying blood to the heart (Shahjehan & Bhutta, 2020). Coronary artery disease is among the most common conditions and causes blood flow impairment hence the delivery of oxygen to the myocardium. The patient’s significant history of hyperlipidemia and hypertension, as well as the family medical history of heart attacks, makes the patient be at risk of coronary artery disease (Regmi & Siccardi, 2020).
Congestive heart failure: The patient indicated that the chest pain is mid-sternum and tight and that when the pain comes, it occurs for a minimum of five minutes and a maximum of half an hour and can be triggered with some hard work. The patient also had a thrill and bruit on the right side and an S3 gallop which usually results from increase fluid (Colyar, 2015). These symptoms suggest heart failure, which limits physical activity to an extent. With the condition, the patient can feel comfortable while resting. However, heart failure symptoms occur upon engaging in ordinary physical activity (Dains et al., 2019).
Carotid artery disease: Carotid artery disease is one of the differential conditions considered for this patient because of the history of high cholesterol (Deeb et al.,2019). The patient also has a family history of both diabetes and hypertension. In addition, the patient has had a lack of exercise, which are all risk factors for carotid artery disease.
GERD: Patients with Gastroesophageal reflux disease usually present with various symptoms such as chest pain, one of the symptoms that the patient had, so it was considered as one of the differential diagnoses. The patient also uses alcohol, which is one of the risk factors.
Previous diagnosis
High blood pressure-controlled through the use of Lopressor
Hyperlipidemia: The patient is using atorvastatin to control the condition
Assignment 1 Digital Clinical Experience Assessing the Heart, Lungs, and Peripheral Vascular System NURS 6512N-32

In order to adequately assess the chest region of a patient, nurses need to be aware of a patient’s history, potential abnormal findings, and what physical exams and diagnostic tests should be conducted to determine the causes and severity of abnormalities.
In this DCE Assignment, you will conduct a focused exam related to chest pain using the simulation too, Shadow Health. Consider how a patient’s initial symptoms can result in very different diagnoses when further assessment is conducted.

To Prepare

Review this week’s Learning Resources and the Advanced Health Assessment and Diagnostic Reasoning media program and consider the insights they provide related to heart, lungs, and peripheral vascular system.
Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation with the Shadow Health
Assignment 1 Digital Clinical Experience Assessing the Heart, Lungs, and Peripheral Vascular System NURS 6512N-32
platform. Review the examples also provided.
Review the DCE (Shadow Health) Documentation Template for Focused Exam: Chest Pain found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
Review the Week 7 DCE Focused Exam: Chest Pain Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
Consider what history would be necessary to collect from the patient.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

DCE Focused Exam: Chest Pain Assignment:

Complete the following in Shadow Health:

Cardiovascular Concept Lab (Required)
Respiratory(Recommended but not required)
Cardiovascular (Recommended but not required)
Episodic/Focused Note for Focused Exam (Required): Chest Pain

Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 7 Day 7 deadline.

Submission and Grading Information
By Day 7 of Week 7

Complete your Focused Exam: Chest Pain DCE Assignment in Shadow Health via the Shadow Health link in Blackboard.
Once you complete your Assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding Assignment in Blackboard for your faculty review.
(Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You can find instructions for downloading your lab pass here: https://link.shadowhealth.com/download-lab-pass
Review the Week 7 DCE Health History Assessment Rubric, provided in the Assignment submission area, for details on completing the Assignment.
Once you submit your Documentation Notes to Shadow Health, make sure to add your documentation to the Documentation Note Template and submit it into your Assignment submission link below.
Complete the Code of Conduct Acknowledgement.

Grading Criteria
To access your rubric:
Week 7 Assignment 1 DCE Rubric
Submit Your Assignment by Day 7 of Week 7
To submit your Lab Pass:
Week 7 Lab Pass
To participate in this Assignment:
Week 7 Documentation Notes for Assignment 1
To Submit your Student Acknowledgement:

Click here and follow the instructions to confirm you have complied with Walden University’s Code of Conduct including the expectations for academic integrity while completing the Shadow Health Assessment.
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Learning Resources
Required Readings (click to expand/reduce)
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Seidel’s guide to physical examination: An interprofessional
approach (9th ed.). St. Louis, MO: Elsevier Mosby.
 Chapter 14, “Chest and Lungs”
This chapter explains the physical exam process for the chest and lungs.
The authors also include descriptions of common abnormalities in the
chest and lungs.
 Chapter 15, “Heart”
The authors of this chapter explain the structure and function of the heart.
The text also describes the steps used to conduct an exam of the heart.
 Chapter 16, “Blood Vessels”
This chapter describes how to properly conduct a physical examination of
the blood vessels. The chapter also supplies descriptions of common
heart disorders.
Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia,
PA: F. A. Davis.
 Chapter 107, “X-Ray Interpretation: Chest (pp. 480–487) (previously read
in Week 6; specifically focus on pp. 480–481)
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health
assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., &
Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Chapter 8, “Chest Pain”
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”
A cough is a very common symptom in patients and usually indicates a
minor health problem. This chapter focuses on how to determine the
cause of the cough by asking questions and performing a physical exam.
Chapter 14, “Dyspnea”
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”
This chapter describes the different causes of heart palpitations and
details how the specific cause in a patient can be determined.
Chapter 33, “Syncope”
This chapter focuses on syncope, or loss of consciousness. The authors
describe the difficulty of ascertaining the cause, because the patient is
usually seen after the loss of consciousness has happened. The chapter
includes information on potential causes and the symptoms of each.
Note: Download the Student Checklists and Key Points to use during your
practice cardiac and respiratory examination.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Chest and lungs: Student checklist. In Seidel’s guide to physical
examination: An interprofessional approach (9th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Chest and lungs: Key points. In Seidel’s guide to physical
examination: An interprofessional approach (9th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Heart: Student checklist. In Seidel’s guide to physical examination:
An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Heart: Key points. In Seidel’s guide to physical examination: An
interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.
Katz, J. N., Lyons, N., Wolff, L. S., Silverman, J., Emrani, P., Holt, H. L., …
Losina, E. (2011). Medical decision-making among Hispanics and non-
Hispanic Whites with chronic back and knee pain: A qualitative study.
BMC Musculoskeletal Disorders, 12(1), 78–85.
This study examines the medical decision making among
Hispanics and non-Hispanic whites. The authors also analyze
the preferred information sources used for making decisions in
these populations.
Smuck, M., Kao, M., Brar, N., Martinez-Ith, A., Choi, J., & Tomkins-Lane,
C. C. (2014). Does physical activity influence the relationship between low
back pain and obesity? The Spine Journal, 14(2), 209–216.
doi:10.1016/j.spinee.2013.11.010
Shiri, R., Solovieva , S., Husgafvel-Pursiainen, K., Telama, R., Yang, X.,
Viikari, J., Raitakari, O. T., & Viikari-Juntura, E. (2013). The role of obesity
and physical activity in non-specific and radiating low back pain: The
Young Finns study. Seminars in Arthritis & Rheumatism, 42(6), 640–650.
doi:10.1016/j.semarthrit.2012.09.002
McCabe, C., & Wiggins, J. (2010a). Differential diagnosis of
respiratory disease part 1. Practice Nurse, 40(1), 35–41.
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.
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.
Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation
as well as other support resources:
Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file].
Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY
Shadow Health. (n.d.). Shadow Health help desk. Retrieved
from https://support.shadowhealth.com/hc/en-us
Document: Shadow Health. (2014). Useful tips and tricks (Version 2)
(PDF)
Document: Student Acknowledgement Form (Word document)
Note: You will sign and date this form each time you complete your DCE
Assignment in Shadow Health to acknowledge your commitment to
Walden University’s Code of Conduct.
Document: DCE (Shadow Health) Documentation Template for Focused
Exam: Chest Pain (Word document)
Use this template to complete your Assignment 1 for this week.
Optional Resource
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.
Required Media (click to expand/reduce)
Advanced Health Assessment and Diagnostic Reasoning
Thoughtful, reasoned questioning leads from initial complaint to diagnosis in these three scenarios.
Note: Close the viewing window after the intro segment and after each diagnosis segment to view the menu.
(12m)
Photo Credit:Provided courtesy of the Laureate International Network of Universities.
SkillStat Learning, Inc. (2019). The 6 second ECG. Retrieved from
http://www.skillstat.com/tools/ecg-simulator#/-home
This interactive website allows you to explore common cardiac rhythms. It
also offers the Six Second ECG game so you can practice identifying
rhythms.
Online media for Seidel’s Guide to Physical Examination
In addition to this week’s media, it is highly recommended that you access and
view the resources included with the course text, Seidel’s Guide to Physical
Examination. Focus on the videos and animations in Chapters 13 and 14 that
relate to the assessment of the chest, heart, and lungs. Refer to Week 4 for
access instructions on https://evolve.elsevier.com/

Name: NURS_6512_Week_7_DCE_Assignment_1_Rubric

Description: To complete the Shadow Health assignments, it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions and the physical assessment areas. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Weeks 1 and 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score.

Grid View
List View

Excellent
Good
Fair
Poor

Student DCE score
(DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.)
Note: DCE Score – Do not round up on the DCE score.

Points Range: 56 (56%) – 60 (60%)

DCE score>93

Points Range: 51 (51%) – 55 (55%)

DCE Score 86-92

Points Range: 46 (46%) – 50 (50%)

DCE Score 80-85

Points Range: 0 (0%) – 45 (45%)

DCE Score <79
No DCE completed.

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.

Total Points: 100

Name: NURS_6512_Week_7_DCE_Assignment_1_Rubric

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Assignment 1: Digital Clinical Experience: Assessing the Heart Lungs and Peripheral Vascular System NURS 6512N-32

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