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

Focus of Assessment: Brian Foster is a fifty-eight-year-old Caucasian male that has come in to be evaluated for three episodes of intermittent chest pain that has occurred over the last month. This is the first time he has sought out medical evaluation. The objective is to discern the cause of the intermittent chest pain by using sound clinical reasoning. Clinical reasoning can only be developed through experience. Each examination of patient brings about a new learning opportunity to further build clinical expertise. 

Subjective Findings             Brian comes to the clinic complaining of three episodes of chest pain in the last month. Two episodes were related to increased activity. The first during heavy yard work and the second walking up four flights of stairs at work. Over eating at his wife’s birthday dinner precipitated the third episode three days ago. During each event, he reports the pain came on suddenly, was in the center of his chest but did not radiate. He describes the pain as a feeling of tightness and being uncomfortable. Pain was reported as five on a numerical pain scale of zero to ten, and lasted only for a few minutes. He denies shortness of breath, syncope, cough, numbness, tingling, nausea, diaphoresis, or heart burn during chest pain events. Resting minimally helps to relieve the pain and thus far he has not taken any medication related to the chest pain. He feels the pain has not been severe enough to consider it an emergency, but does want to have his heart checked out. He currently denies having chest pain and reports his pain as zero. 

Medical History             Brian reports he has a history of hypertension and hyperlipidemia. Prescription medications are Lopressor 100mg daily and Lipitor 20 mg daily at bedtime. For occasional body or headaches, he uses Tylenol or Advil and follows the direction on the bottle. 1200mg of Fish oil is the only supplement he currently takes.  Brian reports an allergy to codeine that causes nausea but no other known allergies. He denies being treated for chest pain in the past, coronary artery disease, diabetes, or respiratory issues. Last year during his annual exam, a twelve-lead electrocardiogram was performed and reported as normal.

Social History Brian is married with one daughter and reports a low stress life at home and work. He does not exercise daily but expressed interest in riding a bike once he is feeling better. Breakfast consists of a granola bar or instant breakfast packet. Occasionally he has a large breakfast consisting of eggs, potatoes and bacon. Lunch is typically a turkey sub or salad. He often grills meat and vegetables for dinner. Brian drinks two cups of coffee each day and one liter of water. He reports no illicit drug use and does not smoke. On the weekends, he drinks two or three beers over the weekend. 

Review of systems In general, he denies fever, fatigue, weight loss, palpitations, syncope, or night sweats. No cardiovascular history of murmur, edema, or coagulopathy. Respiratory history negative for productive or nonproductive cough or shortness of breath. No gastrointestinal history of heartburn, nausea, vomiting, GERD, constipation or diarrhea. No Musculoskeletal issues of back pain, arthritis, or recent injuries. 

Family History             Father had a history of hypertension and hyperlipidemia. Grandfather passed away form myocardial infarction in mid-fifties. Mother and sister both have diabetes. No family history of pulmonary embolism, stroke, or respiratory issues. 

Objective Findings             Brian is a fifty-eight-year-old male alert and oriented to person, place, and time. He makes eye contact throughout visit and is in no distress. He is cooperative to both interview and physical exam. Vital signs are as follows, BP: Right arm 146/90   Left arm 146/88   Pulse: 104 O2Sat: 98%   Resp. rate: 19 Temp. 36.7. Blood Pressure, heart rate elevated despite Lopressor. 

Systems Cardiovascular Heart auscultated S1, S2, and an S3 gallop noted at the 5th left intercostal space at the midclavicular line. Preferably, the patient should be in the left lateral decubitus position for most reliable exam findings. PMI at the fifth intercostal space midclavicular line snapping and brisk but noted lateral shift per palpation. Twelve lead electrocardiogram interpretation, regular rhythm no ST changes. 

Peripheral vascular Right carotid artery bruit noted per auscultation and thrill noted at 3+ per palpation. Left carotid artery no bruit auscultated. No thrill appreciated amplitude 2+ as expected per palpation. JVP three centimeters above sternal angel per inspection normal finding. Brachial, radial, femoral pulses without thrill, expected amplitude 2+ per palpation. Popliteal, tibial, and dorsalis pedis without thrill per palpation. However, amplitude was less than expected at 1+ per palpation. Capillary refill less than three seconds’ times four extremities. No edema noted throughout exam both to visual inspection and palpation.

Respiratory Patient breathing unlabored. Vesicular breath sounds auscultated right and left upper lobes, right middle lobe both anterior and posteriorly. Fine crackles auscultated posteriorly in right and left lower lobes. 

Skin Skin warm, pink, and dry per observation. No tenting per palpation. No edema present. 

Gastrointestinal Stomach soft without tenderness to light or deep palpation. Bowel sounds normoactive times four quadrants per auscultation. No abdominal aortic artery bruit appreciated on auscultation. Unable to palpate liver, spleen, or bilateral kidneys. Tympanic throughout abdomen per percussion. The liver is one centimeter below the right costal margin per percussion. 

Differential Diagnosis             Identifying the attributes of each symptom and pursuing related details are fundamental to recognizing patterns of disease and to generating the differential diagnosis (Bickley, L. S., 2013). Brian is not having what appear to be an emergent episode of chest pain. If he were, differential diagnosis would be myocardial infarction, aortic dissection, acute coronary insufficiency, or pulmonary embolism. He has experienced three episodes of pain over the last month and reports no pain during this visit. Differential diagnosis for nonemergent chest pain will be explored here.  Potential diagnosis based on the patients’ clinical findings are coronary artery disease with stable angina, aortic stenosis, pericarditis, or esophagitis. 

Esophagitis Spasms of the esophagus can mimic angina. Patients usually report that the symptoms are worse after eating spicy foods, large meals, or if they lie down after eating (Dains, J., Baumann, L., & Scheibel, P., 2011).   On exam, patients may have tenderness in the epigastric area during palpation. Brian reports one incident of chest pain related to a large meal. He did mention however, he felt that the episode was coming on before he started to eat. No other issues related to heart burn, nausea or indigestion were reported. This is unlikely the cause of his chest pain. 

Pericarditis             Associated pain is described as sharp focused in the center of the chest and radiates to the back. Risk factors include recent viral or bacterial infection, MI, uremia, and history of autoimmune disease (Dains & Baumann, 2011). Brian denied any recent illnesses or fever. His chest pain does not radiate to his back but stays only in the middle of his chest. On exam, no pericardial friction rub was auscultated. This is unlikely the cause of Brian’s pain.           

Aortic stenosis              Some causes of aortic stenosis include rheumatic fever, congenital anomalies, or calcification of the aortic valve leaflets. One of the early symptoms is angina, which is usually stable and exertion-related. A more serious and later condition is syncope, again associated with exercise. Additional heart sounds, such as an S4, may be heard secondary to hypertrophy of the left ventricle which is caused by the greatly increased work required to pump blood through the stenotic valve (Narayan, P., & Khetan, A. 2015). Brian denies a history of rheumatic heart disease or syncope, however has an S4 gallop per auscultation. Typically, this type of murmur is best heard at the second right intercostal space with the patient leaning forward (Dains, J., Baumann, L., & Scheibel, P., 2011). It was not possible to ask the patient to lean forward during this assessment. Aortic stenosis is a viable diagnosis for this patient. An echocardiogram would be required to confirm this diagnosis. 

Coronary artery disease and stable angina Brian has several positive risk factors for coronary artery disease. He is a male over forty-five with a history of hypertension and hyperlipidemia. He also has a positive family history of myocardial infarction and hyperlipidemia. Atherosclerotic changes in his arteries are the likely culprit of his symptoms. The resulting plaque buildup narrows the blood flow causing angina which is commonly caused by coronary artery disease.  Stable angina refers to chest pain typically described as substernal chest pressure or heaviness (Dains & Baumann, 2011). Brian reports his pain as a tightness in the middle of his chest, however the pain does not radiate. Angina is brought on by increased activity or exertion and lasts for five to ten minutes. It is usually relieved by rest and or medication. Brian reported his pain lasted only a few minutes and felt better with rest. Per auscultation, a bruit is present in the right carotid artery. Per palpation, bilateral lower extremity pulse pressure is 1+ a lower than expected.  The findings may be a result of atherosclerotic changes and result in peripheral vascular disease. Many patients with coronary artery disease (CAD) are affected by concomitant significant peripheral atherosclerosis (Sannino, A., Losi, M., Giugliano, G., Canciello, G., Toscano, E., Giamundo, A., & … Esposito, G., 2015). 

Treatment Plan Diagnostics Brian will require further diagnostic testing before a diagnosis can be made. A repeat ECG is necessary as it may pick up an abnormality not previously found. Evidence of ischemia is not always obvious on an ECG even when the patient is reporting anginal pain (Dains & Baumann, 2011). Laboratory studies including CK-MB, Troponin-I, CBC, BMP, Lipid panel, LFT’s, and HgbA1c. Even though he does not currently have chest pain, if there has been any damage it could possibly still be picked up. CK-MB levels peak twenty-four hours after an MI, but Tropin-I levels will remain elevated seven to ten days after an MI.  Brian has a history of hyperlipidemia and has been taking Lipitor and its effectiveness needs to be reevaluated.   A strong family history for diabetes necessitates a HgbA1c level. An echocardiogram to evaluate his heart function including the four heart valves. This information will determine if he has aortic stenosis. An exercise stress test will determine myocardial function related to blood flow thus coronary artery disease. If stress test and or cardiac enzymes are positive, a cardiac catheterization is warranted.  Right carotid bruit was auscultated indicating need for doppler studies. Patient may need referral to vascular surgeon for carotid disease evaluation. If his symptoms worsen, he needs to seek medical help immediately. 

Medications             Brian’s blood pressure is elevated despite Lopressor. Additional medication is needed to maintain a normal blood pressure. Cardizem is a good second medication to add to Lopressor since he is over fifty-five. If a blood pressure cannot be maintained, an ACE would likely be added to the regimen. He will also need sublingual nitro to use for intermittent chest pain not relieved by rest. 

Education             Any new medications prescribed have potential side effects. Brian needs to be aware of the possibility that sublingual nitro can quickly drop blood pressure and cause headache. Also, he will need to monitor his blood pressure daily with the addition of Cardizem. Hypotension can cause injuries if patient becomes syncopal and falls. If he experiences any side effect, he needs to know what he is supposed to do. Once work up is complete and a diagnosis is made, Brian will need to begin an exercise program. He will also need to address his diet so he is reducing his fat and cholesterol intake. 

Ethical and Legal Standards Ethical codes are systematic guidelines for shaping ethical behavior that answer the normative questions of what beliefs and values should be morally accepted (Butts, J. B., 2017). The building blocks of professional ethics in patient care are, nonmaleficence, beneficence, autonomy, and confidentiality. Simply stated, do no harm, do good, patients have the right to decide what is best for them, and all information exchanged with the patient is confidential. As students, it can be a struggle between learning and doing no harm. The learning is never more important, however, without it harm maybe done. As society becomes more technologically savvy, virtual learning environments have afforded the opportunity to learn in a safe environment. This allows new practioners to go out into the real world with a more highly developed skill set than ever before. 

Cultural Considerations Culturally congruent practice is the application of evidence-based nursing that is in agreement with the preferred cultural values, beliefs, worldview, and practices of the healthcare consumer and other stakeholders. Cultural competence represents the process by which nurses demonstrate culturally congruent practice. Nurses design and direct culturally congruent practice and services for diverse consumers to improve access, promote positive outcomes, and reduce disparities. (Marion, L., Douglas, M., Lavin, M. A., Barr, N., Gazaway, S., Thomas, E., & Bickford, C., 2017). As a student, it is important not to only focus on the clinical symptoms, but to remember the impact of the patients’ culture. This can influence every aspect from the treatment plan to it being implemented. Experts recommend letting patients establish their cultural identity by probing four key areas during the patient interview: the individual’s cultural identity; cultural explanations of the individual’s illness; cultural factors related to the psychosocial environment and levels of function; and cultural elements in the clinician- patient relationship (Bickley, L. S., 2013).   

Conclusion            Heart disease is the leading cause of death in the United States (cdc.org., 2017). Brian Foster has had three episodes of exertional chest pain in the last month. Multiple risk factors put him at an increased risk for coronary artery disease. Once diagnostic exams and laboratory results are complete, a diagnosis can be made as to the cause of his chest pain. Differential diagnosis will be coronary artery disease with stable angina. Aortic stenosis cannot be ruled out. Cardiac catheterization is likely in this case if cardiac enzymes or stress test are positive. One study reported a case where diet and lifestyle modifications, along with lipid lowering therapy, led to the significant regression of coronary artery stenosis (Narayan, P., & Khetan, A., 2015). Once treatment has been successful in releiving Brian’s exertional chest pain, an exercise program, dietary changes, and continuation of lipid lowering medication may yield similar results for him.   

Established chief complaint

Reports chest pain

Asked about onset and duration of chest pain

Reports chest pain started about five minutes ago Reports chest pain has been constant since it began Reports sitting in bed when pain began

Asked to rate chest pain on a scale

Reports current pain is 6/10

Asked about on characteristics of the pain

Describes pain as tight and uncomfortable Denies crushing pain Denies gnawing or tearing pain Denies burning pain

Asked about location of the pain

Reports pain location is in middle of the chest Reports slight pain in left shoulder Denies arm pain Denies back pain Denies jaw pain Denies neck pain

Asked about pain triggers

Reports pain is aggravated by movement

Asked about stress and anxiety

Reports generally low stress lifestyle Denies history of anxiety Denies history of panic attacks

Asked relevant health history

Reports high blood pressure Reports high cholesterol Denies history of pulmonary embolism Denies history of angina Denies history of rheumatic fever Denies history of heart murmur

Followed up on high blood pressure treatment

Reports taking high blood pressure medication Reports high blood pressure medication is Lisinopril High blood pressure medication dose is 20mg High blood pressure medication is taken once daily

Followed up on high cholesterol treatment

Reports taking high cholesterol medication Reports high cholesterol medication is Atorvastatin (Lipitor) Reports high cholesterol medication dose is 20mg Reports high cholesterol medication is taken once daily

Asked history of cardiac tests

Reports recent EKG test Reports annual stress test

Asked about results of cardiac tests

Reports belief that EKG was normal Reports belief that stress test was normal

Asked about substance use

Denies illicit drug use Denies tobacco use Reports moderate alcohol consumption

Followed up on alcohol consumption

Reports drinking only on weekends Reports drinking 2-4 alcoholic drinks per week Reports 2-3 drinks in a single sitting

Asked about exercise

Denies having a regular exercise routine

Asked about most recent meal

Reports most recent meal was previous night at 8 p.m Reports meal consisted of buffalo wings

Asked about typical diet

Reports typical breakfast is granola bar and instant breakfast shake Reports typical lunch is turkey sub Reports typical dinner is grilled meat and vegetables Denies moderating salt intake

Asked about review of cardiovascular system

Denies palpitations Denies swelling Denies circulation problems Denies blood clots Denies easy bleeding Denies easy bruising

Asked about constitutional health

Denies fever Denies chills Denies fatigue Denies sleep issues Denies recent weight changes Denies night sweats Denies dizziness or lightheadedness

Asked about review of respiratory system

Denies cough Denies shortness of breath while lying down Denies blue skin

Asked about throat problems

Denies sore throat Denies difficulty swallowing

Asked about review of gastrointestinal system

Denies diarrhea Denies constipation Denies flatus Denies bloating Denies heartburn or GERD Reports earlier nausea Denies vomiting

Asked relevant family history

Reports family history of heart attack Denies family history of stroke Denies family history of pulmonary embolism