This article covers Advanced Physical Assessment. The patient, Brian Foster a fifty-eight-year-old male complaining of chest pain. A focused health history, physical assessment including examination technique, differential diagnosis, and treatment plan will be documented.
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Advanced Physical Assessment
Introduction
This student will present a patient from the shadow health environment. The patient, Brian Foster a fifty-eight-year-old male complaining of chest pain. A focused health history, physical assessment including examination technique, differential diagnosis, and treatment plan will be documented.
The examination techniques of inspection, palpation, percussion, and auscultation will be documented throughout focused assessment. Care will be taken to address any potential cultural or developmental needs. All ethical and legal standards of professional nursing practice will be adhered to throughout this discourse.
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 wifeās 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 secondsā 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 patientsā clinical findings are coronary artery disease with stable angina, aortic stenosis, pericarditis, or esophagitis.
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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).Ā Ā 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.
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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 Brianās 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, LFTās, 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
Brianās 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 patientsā culture. This can influence every aspect from the treatment plan to it being implemented.
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Experts recommend letting patients establish their cultural identity by probing four key areas during the patient interview: the individualās cultural identity; cultural explanations of the individualās 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
Ā Ā Ā Ā Ā Ā Ā Ā Ā Ā Heart diseaseĀ 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.
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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 Brianās exertional chest pain, an exercise program, dietary changes, and continuation of lipid lowering medication may yield similar results for him.
Bickley, L. S. (2013). Bateās guide to physical examination and history taking. (11th ed.).
Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkin
Butts, J. B. (2017). Ethics in Professional Nursing Practice. Retrieved from
Centers for Disease Control (2017). Heart Disease and Statistics. Retrieved from http://cdc.gov
Dains, J., Baumann, L., & Scheibel, P. (2011). Advanced health assessment & clinical diagnosis in primary care (4th ed.). St. Louis, MO: Mosby Elsevier.
Marion, L., Douglas, M., Lavin, M. A., Barr, N., Gazaway, S., Thomas, E., & Bickford, C.
(2017). Implementing the New ANA Standard 8: Culturally Congruent Practice. Online
Journal Of Issues In Nursing, 22(1), 1. doi:10.3912/OJIN.Vol22No01PPT20
Narayan, P., & Khetan, A. (2015). Dramatic regression of coronary artery stenosis three years
after diagnosis. Perfusion, 30(7), 587-589. doi:10.1177/0267659114567934
Nursing World. (2017). About Code of Ethics. Retrieved from https://nursingworld.org
Sannino, A., Losi, M., Giugliano, G., Canciello, G., Toscano, E., Giamundo, A., & … Esposito,
- (2015). Aortic and Mitral Calcification Is Marker of Significant Carotid and Limb
Atherosclerosis in Patients with First Acute Coronary Syndrome. Echocardiography,
32(12), 1771-177.
Shadow Health. (2017). Brian Foster focused exam: chest pain. Retrieved from
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Related FAQs
1. What are advanced physical assessment skills in nursing?
Appropriate, accurate, and timely assessment by nurses is the cornerstone of maintaining patient safety in hospitals. The inclusion of āadvancedā physical assessment skills such as auscultation, palpation, and percussion is thought to better prepare nurses for complex patient presentations within a wide range of clinical situations.
2. What is the module name for Advanced Physical assessment?
Module name Advanced Physical Assessment, Critical thinking and Diagnostic reasoning across the Lifespan Module code APM024 School School of Health Sciences Department or equivalent Division of App lied Biological, Diagnostic and Therapeutic Sciences UK credits 30 ECTS 15 Level 7 MODULE SUMMARY Module outline and aims
3. What is advanced physical health assessment (APHA)?
Advanced Physical Health Assessment is a core module on MSc Advanced Clinical Practice and can be counted at a later date. It can also be taken as CPD with no academic accreditation, in which case a ācertificate of attendanceā will be provided.
4. What is MSc advanced physical health assessment?
Demonstrate ability to competently produce high quality clinical records reflecting critical thinking and decision making (Clinical component) Advanced Physical Health Assessment is a core module on MSc Advanced Clinical Practice and can be counted at a later date.