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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.

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?


Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.


• 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.

o 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.

o 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.

o 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.

o Chapter 107, “X-Ray Interpretation: Chest (pp. 480–487) (specifically focus on pp. 480–


• Chapter 107, “X-Ray Interpretation: Chest (pp. 480–487)Download “X-Ray Interpretation: Chest

(pp. 480–487)

• 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”Download 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”Download 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”Download 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”Download 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”Download 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.

• Bansal, M. (2020). Cardiovascular disease and COVID-19. Links to an external site. Diabetes &

Metabolic Syndrome: Clinical Research & Reviews, 14(3), 247–250.


Links to an external site.

• Jolobe, O. M. (2021). Differential diagnosis of the association of gastrointestinal symptoms and

ST segment elevation, in the absence of chest pain. Links to an external site. The American

Journal of Emergency Medicine, 49, 137–141. https://doi.org/10.1016/j.ajem.2021.05.067

Links to an external site.

Shadow Health Support and Orientation Resources

Use the following resources to guide you through your Shadow Health orientation as well as other

support resources:

• Shadow Health. (2021). Welcome to your introduction to Shadow Health. Links to an external


• Shadow Health. (n.d.). Shadow Health help desk. Links to an external site.Retrieved from


• Shadow Health. (2021). Walden University quick start guide: NURS 6512 NP students Download

Walden University quick start guide: NURS 6512 NP students. Links to an external


• Document: DCE (Shadow Health) Documentation Template for Focused Exam: Chest Pain (Word

document)Download DCE (Shadow Health) Documentation Template for Focused Exam: Chest

Pain (Word document)

Use this template to complete your Assignment 1 for this week.


• 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

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


• 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?


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



Week 7

Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.

History of Present Illness (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. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom:

1. Location

2. Quality

3. Quantity or severity

4. Timing, including onset, duration, and frequency

5. Setting in which it occurs

6. Factors that have aggravated or relieved the symptom

7. Associated manifestations

Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.

Allergies: Include specific reactions to medications, foods, insects, and environmental factors.

Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.

Past Surgical History (PSH): Include dates, indications, and types of operations.

Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.

Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.

Immunization History: Include last Tdp, Flu, pneumonia, etc.

Significant Family History: Include history of parents, Grandparents, siblings, and children.

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History).
Remember that the information you include in this section is based on what the patient tells you.
You will only need to cover systems pertinent to your CC, HPI (N/A, UNKNOWN is not acceptable, make up the information if you need to). To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.

General: Include any recent weight changes, weakness, fatigue, or fever, but
do not restate HPI data here.

Cardiovascular/Peripheral Vascular:





OBJECTIVE DATA: 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 unless you are doing a total H&P.
Do not use WNL or normal. You must describe what you see.

Physical Exam:

Vital signs: Include vital signs, ht, wt, temperature, and BMI and pulse oximetry.

General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.

Cardiovascular/Peripheral Vascular: Always include the heart in your PE.

Respiratory: Always include this in your PE.





Diagnostic Test/Labs: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses with rationale for each one documented OR ones that were mentioned during the SH assignment.

ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled.

© 2021 Walden University

Studocu is not sponsored or endorsed by any college or university

Advanced Assessment Week 7

Advanced Health Assessment & Diagnostic Reasoning (Walden University)

Studocu is not sponsored or endorsed by any college or university

Advanced Assessment Week 7

Advanced Health Assessment & Diagnostic Reasoning (Walden University)

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Week 7 – Chest Pain Documentation

Shadow Health Digital Clinical Experience – Focused Exam

Name: BF Gender: Male Age: 58 Race/Ethnicity: White/Caucasian


Chief Complaint (CC): Chest pain

History of Present Illness (HPI): This is a 58-year-old white male presenting today with a complaint of

chest pain. Patient states that “I have been having some troubling chest pain in my chest now and then
for the past month.” Patient describes the pain as periodic and that it occurs during physical activities

such as “mowing the lawn and walking up the stairs.” Describes chest pain as midsternal “tightness and
discomfort” relieved by rest. Patient reports three episodes of chest pain in the past month with the last

pain episode being about three days ago. Denies pain radiation, palpitations of chest. Does not take any

medications for chest pain. Takes lisinopril and Atorvastatin and uses Tylenol and Ibuprofen for

occasional headaches. Patient denies chest pain or palpitations during this interview and denies SOB,

cough, or change in sputum consistency. Denies abdominal tenderness, heartburn, nausea, or vomiting.

Patient works as a civil engineer, lives with wife of 28 years and has two grown children. Admits to not

exercise for over two years now because his bike was stolen. He reports eating healthy and socially

drinking alcohol. Denies tobacco or drug use.

1. Location: Chest/substernal

2. Quality: Tightness/discomfort

3. Quantity or severity: Discomfort/Tightness, 5/10

4. Timing, including onset, duration, and frequency: At the beginning of the month. Lasts a couple

of minutes. Happened three times over the past month

5. Setting in which it occurs: During exhaustion

6. Factors that have aggravated or relieved the symptom: Precipitated by physical activities. Pain

is relieved by rest.

7. Associated manifestations: Does not radiate elsewhere

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Medications: Atorvastatin (20 mg PO HS), Lisinopril (20 mg PO HS), Fish oil (1200 mg PO daily),

Ibuprofen (PRN), Tylenol (PRN)

Allergies: Codeine (nausea, vomiting)

Past Medical History (PMH): HTN, HLD

Past Surgical History (PSH): None

Sexual/Reproductive History: Denies hx of STIs, denies multiple sexual partners. Not on birth control,

wife is post-menopausal

Personal/Social History: Eats healthy, drinks 2-3 beers per weekend, denies tobacco use, denies drug

use. Likes sports, fishing, small electronic repairs, and watching son’s body building competition.
Heterosexual male, civil engineer who has been married for 27 years with two children.

Immunization History: Up to date on Tdp, Flu, COVID, pneumonia vaccinations

Significant Family History: Father died of colon cancer. Mother and sister have diabetes. Daughter has

asthma. Maternal grandmother died of breast cancer. Maternal grandfather died of a heart attack.

Hypertension runs in the family.

Review of Systems:

General: Reports gaining 15-20 lbs. over last couple of years. Denies weakness, fatigue, or fever.

Cardiovascular/Peripheral Vascular: Denies chest pain currently, palpitations

Respiratory: Denies SOB, cough, sputum

Gastrointestinal: Denies abdominal tenderness, nausea, or vomiting

Musculoskeletal: Denies weakness or musculoskeletal pain

Psychiatric: Denies stress, depression, or other mental heal problems. Denies thoughts of

harming others or self.

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Physical Exam:

Vital signs: Left arm BP: 146/88, right arm BP: 146/90, HR: 104, RR: 19 O2Sat: 98%, T: 36.7oC

General: Patient is presentable and pleasant. Has an upright gait, with no visible physical deficits. He is

alert and oriented, and mildly anxious.

Cardiovascular/Peripheral Vascular: S1S2, no extra sounds, JVP 3 cm above sternal angle,

No jugular venous distention

Respiratory: Always include this in your PE.

Gastrointestinal: Appearance normal, no skin discoloration, no masses; Bowel sounds are

normo-active in all quadrants

Musculoskeletal: Full strength in all extremities

Neurological: Alert, oriented x 4, LOC intact.

Skin: Diminished freckles on bilateral hands, nails unchanged

Diagnostic Test/Labs: CBC, BMP/Renal Panel, Troponin, CXR, CT-chest, Stress test, Heart Cath, EKG,

Echocardiogram, Myocardial Perfusion Imaging


Priority diagnoses with differential diagnoses:

Acute Myocardial Infarction

Atherosclerosis: signs include chest pain (angina), cold sweats, dizziness, extreme tiredness,

heart palpitations (feeling that your heart is racing), shortness of breath, nausea, and weakness

(National Heart, Lung, and Blood Institute, 2022)

Stable Angina: The pain onset is usually gradual, brought on and exacerbated by exercise and

stress (Dains et al., 2019)

Pulmonary Embolism: Chest pain that may become worse during physical activities and when

breathing in (American Lung Association, 2020).

Acute Coronary Syndrome (ACS)

Unstable Angina: chest discomfort or pain caused by an insufficient flow of blood and oxygen to

the heart (Goyal & Zeltser, 2022)

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ST-elevation myocardial infarction: occurs due to occlusion of one or more coronary arteries,

causing transmural myocardial ischemia which in turn results in myocardial injury or necrosis

(Akbar et al., 2021)

Non-ST-elevation myocardial infarction: Male patients typically present with chest

pressure/discomfort lasting at least several minutes, at times accompanied by sweating,

dyspnoea, nausea, and/or anxiety. Women present more commonly with middle/upper back

pain or dyspnoea and similar associated symptoms (Baruah, 2022).

– ACA may not be the most common etiology in patients presenting with chest pain, but excluding ACS is

vital because of the mortality associated with untreated myocardial infarction (Brown, 2022).

Coronary and Vascular Infections

Myocarditis: The chest pain is caused by ischemia or arrhythmia following inflammatory cell

death (Dains et al., 2019).

Pericarditis: The pain associated with pericarditis is described as sharp, located in the center of

the chest, short–lived, episodic, and radiating to the back in the trapezial area (Dains et al.,


Pleuritis: Pleuritic chest pain can be a manifestation of pneumonia or can represent pleural

inflammation, usually after a viral upper respiratory tract infection (Dains et al., 2019).

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Akbar, H., Foth, C., Kahloon, R., & Mountfort, S. (2021, August 9). Acute st elevation myocardial

infarction – NCBI bookshelf. National Library of Medicine. Retrieved from


American Lung Association. Pulmonary embolism symptoms and diagnosis. (2020). Retrieved from



Baruah, R. (2022, September 16). Non-ST-Elevation Myocardial Infarction (NSTEMI). BMJ Best Practice.

Retrieved from https://bestpractice.bmj.com/topics/en-gb/3000113

Brown, J. E. (2022, September 16). Evaluation of chest pain. BMJ Best Practice US. Retrieved from


Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in

primary care (6th ed.). Elsevier Mosby.

Goyal, A., & Zeltser, R. (2022, September 18). Unstable angina. National Library of Medicine. Retrieved

from https://www.ncbi.nlm.nih.gov/books/NBK442000/

U.S. Department of Health and Human Services. (2022, March 24). What is atherosclerosis? National

Heart Lung and Blood Institute. Retrieved from https://www.nhlbi.nih.gov/health/atherosclerosis

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