NR 545 Week 3 Focused Exam Write-Up Example

Focused Exam Write-Up: Testing the Congestion Account of a 64-Year-Old Patient's Orthopnea at the Neck, Heart, Lungs, Abdomen and Legs, With Each System Chosen for a Stated Physiological Reason

Student Name

College of Nursing, Chamberlain University

NR 545: Pharmacology, Physical Assessment, and Pathophysiology

Instructor Name

Month Day, Year

Focused Exam Write-Up: Testing the Congestion Account of a 64-Year-Old Patient's Orthopnea at the Neck, Heart, Lungs, Abdomen and Legs, With Each System Chosen for a Stated Physiological Reason

The Question This Examination Answers

The Week 2 mechanism write-up proposed that this patient's breathlessness, orthopnea, nocturnal waking and ankle swelling are caused by raised filling pressures from a left ventricle ejecting only 30% of its volume. It predicted three findings: an elevated jugular venous pressure, pulmonary congestion and pitting edema. It also predicted that extremities would be warm and pulse pressure adequate, because resting output appeared sufficient. The question for this focused examination is whether the patient is congested, and if so, whether perfusion is preserved. That places the patient in one of four hemodynamic profiles, warm or cold and wet or dry, which predicts outcome and guides therapy (Nohria et al., 2003).

History, Cut to What Matters

Subjective. A 64-year-old retired machinist reports breathlessness climbing one flight of stairs, worsening over three weeks. The patient sleeps on two pillows, up from one, and woke twice in the past week breathless, relieved by sitting up. Ankle swelling appears by evening and resolves overnight. The patient denies chest pain at rest or on exertion, palpitations, fainting, fever, cough with sputum or calf pain. Weight has risen by about 3 kg in a month by home scale. The patient reports taking all medications and has not added salt substitutes or anti-inflammatory drugs. Past history includes hypertension, type 2 diabetes and 30 pack-years of smoking, stopped 10 years ago.

Other history, such as surgical and family history, was reviewed and did not change what would be examined, so it is not repeated here.

The patient uses no over-the-counter cold remedies or herbal products and drinks alcohol rarely, which matters because both alcohol and nonsteroidal anti-inflammatory drugs can worsen heart failure.

General and Vital Signs

Reason: overall perfusion, sympathetic activation and whether the patient is breathless at rest.

Alert and conversing in full sentences, sitting upright. Blood pressure 138/84 mmHg seated, right arm, repeated after five minutes. Heart rate 92 per minute, regular. Respiratory rate 20 per minute. Oxygen saturation 95% on room air. Temperature 36.8 °C. Weight 91.4 kg, height 175 cm. Proportional pulse pressure (systolic minus diastolic, divided by systolic) is 0.39, well above the threshold associated with low cardiac output in chronic heart failure (Stevenson & Perloff, 1989).

Neck

Reason: the jugular venous pressure is the most direct bedside estimate of right-sided filling pressure, and the mechanism predicts it is raised.

With the patient at 45 degrees, the internal jugular pulsation on the right is visible 6 cm above the sternal angle; adding the conventional 5 cm puts the estimated jugular venous pressure near 11 cm of water. Sustained firm pressure on the right upper quadrant lifted the pulsation by 4 cm, sustained while pressure was held, a positive abdominojugular test. No carotid bruits.

The waveform had two peaks per beat, could not be palpated and fell when the abdominal pressure was released, confirming it was venous rather than carotid.

Heart

Reason: a dilated ventricle predicts a displaced apex and possibly a third heart sound; a murmur of aortic stenosis or mitral regurgitation would suggest a different or additional cause.

Apex felt one space low, in the sixth interspace, and out at the anterior axillary line; diffuse, about 3 cm across. First and second heart sounds normal. A low-pitched third heart sound is heard at the apex with the bell, patient in left lateral position. A soft grade 2/6 holosystolic murmur at the apex, not radiating. No murmur at the right upper sternal border, no rub.

The apex was re-examined with the patient turned onto the left side, which brings the ventricle closer to the chest wall and makes a low-pitched filling sound easier to hear through the bell.

Lungs

Reason: pulmonary congestion is the central prediction; wheeze or focal signs would point toward lung disease, which the smoking history makes plausible.

Chest expansion symmetric. Percussion resonant except for mild dullness at the right base. Fine inspiratory crackles at both bases, reaching about a third of the lung height on the right side, not clearing with cough. No wheeze. No bronchial breathing.

Abdomen

Reason: hepatic congestion and ascites follow raised right-sided pressure.

Liver edge palpable 2 cm below the right costal margin, smooth and mildly tender. No shifting dullness.

Extremities

Reason: dependent edema follows fluid retention; temperature and capillary refill estimate perfusion.

Pitting edema to mid-shin bilaterally, graded 2+, leaving an indentation that persists for about 15 seconds. Hands and feet warm. Capillary refill under two seconds. Calves soft, equal in circumference, not tender. Dorsalis pedis pulses palpable bilaterally.

Systems Examined to Exclude

Thyroid examined because hyperthyroidism can cause high-output failure and tachycardia: not enlarged, no nodules, no tremor. Skin examined for signs of infection or cellulitis that might explain leg swelling: none.

What the Examination Changed

The congestion account survived. Every predicted finding was present: an elevated jugular venous pressure with a positive abdominojugular test, bibasilar crackles, pitting edema and a third heart sound. The third heart sound matters most, since in breathless patients it substantially raises the probability of heart failure (Wang et al., 2005). The prediction of preserved perfusion also held: warm extremities, brisk capillary refill and a proportional pulse pressure well above the low-output threshold. The patient is warm and wet.

Two findings added to the account. The apical holosystolic murmur is most likely functional mitral regurgitation from a dilated ventricle, which the echocardiogram should confirm. The dullness at the right base suggests a small effusion. Neither changes the conclusion. What the examination weakened was the lung disease alternative: no wheeze, no prolonged expiration and no focal signs. It is not excluded, and spirometry after decongestion would settle it. The next step is to weigh these findings against the alternative explanations for the breathlessness in a single integrated analysis.

The pertinent negatives were chosen, not listed. No wheeze and no prolonged expiration argue against active obstructive lung disease. Soft, symmetric calves without tenderness lower the concern for a deep vein thrombosis as a source of embolism. No murmur at the right upper sternal border makes significant aortic stenosis unlikely, which matters because it would change both the cause and the treatment. A normal temperature and no focal chest signs make pneumonia an unlikely source of the crackles. Each negative removes an alternative the history alone had left open.

References

Nohria, A., Tsang, S. W., Fang, J. C., Lewis, E. F., Jarcho, J. A., Mudge, G. H., & Stevenson, L. W. (2003). Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. Journal of the American College of Cardiology, 41(10), 1797-1804. https://doi.org/10.1016/S0735-1097(03)00309-7

Stevenson, L. W., & Perloff, J. K. (1989). The limited reliability of physical signs for estimating hemodynamics in chronic heart failure. JAMA, 261(6), 884-888. https://doi.org/10.1001/jama.1989.03420060100040

Wang, C. S., FitzGerald, J. M., Schulzer, M., Mak, E., & Ayas, N. T. (2005). Does this dyspneic patient in the emergency department have congestive heart failure? JAMA, 294(15), 1944-1956. https://doi.org/10.1001/jama.294.15.1944