Part A
Example assessment 2
Part A
Patients presenting problem
Kirsty is a 40 yr-old woman, brought to the Emergency Department by a friend. She presents with a two day history of shortness of breath and left sided chest pain which is worse on inspiration.
Initial observations
Signs & Symptoms
Temperature 36.8 C, HR 132 & regular, BP 140/85, resps 26br/p/min
Ht 160 cm, weight 92 kg (BMI 36)What were the signs and symptoms (clinical manifestations)?
Kirsty has developed a cough (haemoptysis). Over previous 24 hours
Diaphoretic, speaking in short sentences.
Obese, Caucasian woman in obvious respiratory distress.
Preliminary Investigations
ECG (see appendix). Sinus tachycardia with RBBB. T wave inversion leads III, V1-V3. (? Associated with RBBB). No other ischaemic changes noted.
Affective / Emotion Signs & Symptoms
Well-groomed woman, alert, crying & anxious.
Orientated to time and place.
Walking into ED slowly supported by friend. Gait & mobility appropriate for her age & presenting pain / anxiety.
Thought content - States she is scared because she thinks she is having a heart attack and the pain is frightening and makes it difficult to breathe. (Her friends husband recently passed away from AMI age 43yrs). Also concerned about important work meeting this afternoon.
Behavioural signs & symptoms - Responds to questioning & instructions appropriately considering situation & thought content. Hugging chest. Closing eyes and grimacing at times with pain, clenching jaw. Pain / SOB has made it difficult to sleep, Has attended usual ADLs until this morning when pain worsened.
History
Medical history
Appendectomy age 7. No known diabetes, cholesterol unknown. Blood pressure always borderline high. No history premature cardiovascular / cerebrovascular disease. Parents/siblings alive & well. Regular medications Nexium 40mg nocte (for GORD), Yasmin 3mg/0.03mg (for oral contraception). Panadeine x 2 at 9am this morning for pain.
Psychiatric history
Sometimes feels anxious & depressed but hasnt sought treatment.
Drug and Alcohol history
Smokes 15 cigarettes / day for 20 years. (15 pack/year history)
ETOH 2 glasses red wine most days.
No recreational drug use.
Current social supports
No family in Sydney. Ex-husband could help out if required but would prefer not to rely on him. Two close friends. Good neighbours.
Social circumstance
Recently divorced, Most family in the UK (Patient is British 10 years in Australia).
Lives alone
Works as an international marketing consultant. Has just returned from Europe (direct flight two days ago)
Other Considerations
Kirsty has a couple of pets at home that will need feeding. Her ex-husband will help.
Kirsty does not follow a particular religion and does not wish spiritual support at this time.
Kirsty doesnt have her personal belongings with her. Her friend will bring a few things in from home.
Investigations
Bloods taken for Troponin, UECS, FBC, D-Dimer.
Part B
This is an example only.
In your essay, please limit use of abbreviations to increase readability. Non-standard abbreviations should not be used unless they appear at least three times in the text.
Within Part B, I suggest a more formal essay writing style rather than what is shown below. For instance, dont ask rhetorical questions, limit use of e.g., ( ), and ? to describe a query.
1a) What is going on here?
(Patients presentation what did the person present with? (one paragraph)
Kirsty is a 40 year old woman works as an international marketing consultant with recent history of long-haul air travel 2 days ago. Obese, presents with 2-day history of left-sided, pleuritic chest pain and haemoptysis.
(Evident clinical manifestations signs and symptoms. Please include both observed mental and physical health signs and symptoms)
The patient is anxious as a result of her significant pain, her concern that she might be having a heart attack in light of the recent death of a friends husband from premature AMI. She is tachycardic (HR 132 bpm), tachypnoeic (resp rate 26) and mildly hypertensive (BP 140/85). ECG shows sinus tachycardia, rate 132bpm & right-bundle branch block (rSR wave V2) with T-wave inversion in Lead III & V1-3 (ischaemic, ? from RBBB, ? right heart strain pattern). Mood, affect, thought content & cognition appropriate to age, physical presentation & personal concerns. Cardiac risk factors hypertension, Smoker 15 cigarettes per day, etc Develop this section as per instructions (Max 750 words) Please put the word count after each section and do not go over the prescribed word count
1b) Pathophysiology of clinical manifestation.
Kirsty has presented with a right Bundle branch block and T wave inversion in leads III, and V1 3. RBBB is a normal ECG variant in some patients (Bloggs 2012). In RBBB, activation of the right ventricle is delayed as depolarisation has to spread across the septum from the left ventricle. The left ventricle is activated normally, meaning that the early part of the QRS complex is unchanged. The delayed right ventricular activation produces a secondary R wave (R) in the right precordial leads (V1-3) and a wide, slurred S wave in the lateral leads. Delayed activation of the right ventricle also gives rise to secondary repolarization abnormalities, with ST depression and T wave inversion in the right precordial leads. In isolated RBBB the cardiac axis is unchanged, as left ventricular activation proceeds normally via the left bundle branch. An example can be seen in the strip below (LITFL ECG library, 2014).
Right Bundle branch block may have a number of pathological causes. Right ventricular hypertrophy / cor pulmonale, pulmonary embolus, ischaemic heart disease, rheumatic heart disease, myocarditis or cardiomyopathy, degenerative disease of the conduction system, congenital heart disease (e.g. atrial septal defect) (Brown & Green, 2013) An RSR pattern in V1-3 may also be caused by Brugada syndrome an ECG pattern associated with malignant ventricular arrhythmias (Rumplestilstkin, 2010).
Kirstys history suggests that the RBBB and other features of her ECG could be associated with pulmonary embolism (PE). Sinus tachycardia is seen in 44% of patients with PE due to the poor return of oxygen rich blood to the heart because of a clot in the pulmonary stystem. Complete RBBB (with QRS wider than 3 small square on the ECG paper) or incomplete RBBB (rSR in V1 or V2 but normal QRS width) is seen in 18% of PE patients & is associated with increased mortality (Obama 2009).
Along with the RBBB, Kirsty seems to be exhibiting a right ventricular strain pattern T wave inversions in the right precordial leads (V1-4) the inferior leads (II, III, aVF). This pattern is seen in up to 34% of patients with PE and is associated with high pulmonary artery pressures (Ghandi 2013).
Kirsty is also exhibiting a right axis deviation seen in 16% of PE patients.Extreme right axis deviation may occur, with axis between zero and -90 degrees, giving the appearance of left axis deviation (pseudo left axis) (Rambo 2008).
As Kirsty is presenting with chest pain and T wave inversion, the possibility of acute coronary syndrome should also be considered. While T wave inversions are commonly associated with acute coronary syndromes, there are several findings associated with pulmonary embolism that differentiate this diagnosis from ACS: ACS is rarely associated with tachycardia; both ACS and PE will present with elevated troponin; ultrasonography may be useful in differentiating the two. (Pitt & Jolie 2014). Kosuge et al (2002) have shown that simultaneous inversion in III and V1 are diagnostically significant: Negative T waves in leads III and V1 were observed in only 1% of their patients with ACS compared with 88% of patients with Acute PE.
How did the presenting problem arise in pathophysiological terms?
Kirstys physical presentation is suggestive of pulmonary embolism. There is also the possibility of an acute coronary syndrome although her symptoms would be considered atypical. The ECG changes in pulmonary embolism are due to dilation of the right atrium and right ventricle with consequent shift in the position of the heart, right ventricular ischaemia and increased stimulation of the sympathetic nervous system due to pain, anxiety and hypoxia (Abbott & Hockey 2015).
(Note Maximum of 750 word in this section link the chosen sign or symptom back to the presentation of your patient & your developing diagnostic reasoning about what you think is happening.)
What else do I need to know? (Max 500 words)
Does Kirsty have elevated cardiac enzymes? At this point it is important to exclude an acute coronary syndrome. It is important to know Kirstys troponin level, however, the result should be considered with caution. Clinical evidence of myocardial ischemia is necessary to support AMI diagnosis because elevated troponin elevations may reflect myocardial injury that is not necessarily due to an acute coronary syndrome (ACS). Increased blood concentrations of troponin can also be seen in a variety of other diseases, including major pulmonary embolism. Troponin measurements do not enable us to distinguish specifically between coronary and non-coronary causes of chest pain, but can help to identify myocardial-cell injury in pulmonary embolism associated with RV dysfunction. Furthermore, positive troponin I tests appear to directly reflect the impairment of pulmonary blood flow as assessed by a significant association with the number of segmental defects in lung scans and therefore the seriousness of the presentation (Hai & Lowe, 2-11).
Does Kirsty have a personal or family history of embolism or of other predisposing factors? Kirsty is at higher risk if she or any of her family members have had venous blood clots or pulmonary embolism in the past. Other conditions such as heart failure, atrial fibrillation, and certain cancers such as ovarian cancer and lung cancer can increase the likelihood of clots. Women with a personal or family history of breast cancer who are taking tamoxifen or raloxifene also are at higher risk of blood clots. Recent surgery can also increase the chance of embolism (Samson & Delilah 2010).
What further information required at this point?
Get results of D-Dimer D-dimer is a fibrin degradation product (or FDP), a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis. D-dimer concentration may be determined by a blood test to help diagnose thrombosis. D-dimers are not normally present in human blood plasma, except when the coagulation system has been activated, for instance because of the presence of thrombosis While a negative result practically rules out thrombosis, a positive result can indicate thrombosis but does not rule out other potential causes. Its main use, therefore, is to exclude thromboembolic disease where the probability is low (Fatt & Finn 2005).
Urgent CTPA should be arranged as a definitive diagnostic tool for PE. It is a preferred choice of imaging in the diagnosis of PE due to its minimally invasive nature for the patient, whose only requirement for the scan is an intravenous line. CTPA is the gold standard for diagnosis of pulmonary embolism. A normal CTPA scan will show the contrast filling the pulmonary vessels, appearing as bright white. Any mass filling defects, such as an embolus, will appear dark in place of the contrast, filling/blocking the space where blood should be flowing into the lungs.
Other assessments / investigations required?
Regular ECGs while chest pain continues until further evidence of PE established. Particular attention should be paid to signs of ST elevation depression, poor R wave progression, & further T wave abnormalities.
Oxygen saturations and arterial blood gasses should be taken to guide oxygen therapy & ventilatory support.
Results of FBC and EUCs should be documented to rule out other contributing / resulting issues.
What aspects of the health history need further information?
Pulmonary embolism usually follows a deep vein thrombosis peripherally (Munroe 2011). It should be established whether Kirsty presented with any calf pain, redness or swelling in her lower leg and if she ever used any DVT prophyllaxis when travelling eg stockings, limb exercises. Lower limb ultrasound (Doppler) could establish the presence of a DVT in her calves, picking up any abnormality in her normal venous flow (Bonnie & Clyde 2007).
Further evidence of coronary risk could be determined including physical inactivity, any past results re blood glucose testing or cholesterol screening.
While not a priority, formal screening for depression & anxiety could occur during this admission.
The two level Wills score can assist diagnosis and Kirsty scores 5.5 based on her clinical presentation suggesting PE is likely.
What does all this mean?
Chest pain can signify several pathologies including acute coronary syndromes, aortic dissection, cardiac tamponade, pneumonia and pneumothorax (Rank & File 2009). Several factors suggest that Kirtsys presentation is most consistent with pulmonary embolism including her history of recent long haul flight, and her ECG presentation with right bundle branch block, sinus tachycardia and right heart strain pattern (Obama 2009). Other salient factors include her history of smoking - for reasons that aren't well-understood, tobacco use predisposes some people to blood clot formation, especially when combined with other risk factors (Green & Gold 2006). Kirtsy is obese (BMI 36). Excess weight increases the risk of blood clots particularly in women who smoke or have high blood pressure (Short & Curly 2012). Kirsty is taking supplementary eostrogen. The estrogen in birth control pills and in hormone replacement therapy can increase clotting factors in your blood, especially if you smoke or are overweight (Jinn & Tonick 2014). While Kirtsys CXR was normal, this absence of abnormality is is common in pulmonary embolism (Jaque & Jil 2013). Kirtsy presented with haemoptysis. People with pulmonary emboli often present with hemoptysis as a result of ischemic pulmonary parenchymal necrosis (Smith & Jones 2015).
Definitive diagnosis using CTPA is the most important priority and subcutaneous low molecular weight heparin should be commenced while awaiting further testing. Anticoagulation is the main therapy for acute pulmonary embolism (PE). Its goal is to decrease mortality by preventing recurrent PE. In the only trial ever performed that compared treatment with anticoagulants to no treatment, anticoagulation decreased mortality and this has been further demonstrated in subsequent uncontrolled trials (Hull 2014).
Kirsty is understandably anxious. Reassuring her (eg that it is unlikely she is having a heart attack), providing her with pain relief and talking to her about breathing more slowly and deeply if possible could alleviate her anxiety and to some degree reduce the subsequent sympathetic response. It appears that Kirsty may have an underlying anxiety depression that could be further investigated (eg with a screening tool) & managed once her immediate physical needs have been met. This may be dealt with in her discharge letter to the GP or with a referral for later outpatient follow-up if this appears to be a significant issue for her. This would also serve to reduce a known cardiovascular risk.
(Max 500 words)
References
Please list refences using APA7
Miss Jones, Background notes
Miss Jones is a 67-year-old widowed woman. Her daughter brought her into the emergency department yesterday due to difficulty breathing. She smokes pack per day and has type 2 diabetes. She is otherwise healthy and well with no recent illnesses apart from the presenting symptoms. She has been retired for the past 2 years but use to work as an accountant. Miss Jones is active in her Protestant church.
She takes metformin 500 mg twice a day at home.
Allergies Nil known
Partial assessment & observations
BP 150/80, HR 96, Temperature 36.5C, SpO2 95% on 2L nasal prongs.
Her skin is slightly cool to touch, and she has pale extremities with +2 oedema in her legs bilaterally. Her breath sounds have bilateral, anterior crackles, and she has an occasional non-productive cough that has been increasing in frequency.
Video 1 https://accessmedicine-mhmedical-com.ezproxy.library.sydney.edu.au/MultimediaPlayer.aspx?MultimediaID=16633709Video 2 https://accessmedicine-mhmedical-com.ezproxy.library.sydney.edu.au/MultimediaPlayer.aspx?MultimediaID=16633710
NURS5012 Assessment 2:
Comprehensive Clinical Assessment Reporting Guidelines
Students should use an assessment approach that is appropriate for their clinical setting and the patients clinical presentation (e.g. An assessment of normal milestones by an early childhood nurse would have different priorities and inclusions to an assessment of an acutely ill emergency patient, or an outpatient oncology clinic patient):
Patients presenting problem
What was the patients initial complaint
Initial observations
What were the signs and symptoms (clinical manifestations)?
O Include observations about their appearance
O Include any other preliminary investigations
O Other assessments (e.g., neurological/cardiac/renal etc.)
What were their affective/emotional signs and symptoms?
O Mood/affect/expressed emotion is it specifically about what they
presented with?
What were their cognitive and psychological signs and symptoms?
O Include level of consciousness; alertness; orientation; attention and
concentration
o Include memory if applicable
o Include speech and thought pattern and content
What were their behavioural signs and symptoms?
O What was the person doing?
O Include gait, gestures, facial expression, non-verbal language
History
Medical history
Psychiatric history
Drug and Alcohol history
Current social supports
Social circumstance
Other Considerations
Cultural
Environmental
Spiritual
Investigations
Specify the investigations that have occurred to date and the outcomes (if
known)
Textbook to assist with pathophysiology
https://sydney.primo.exlibrisgroup.com/discovery/search?vid=61USYD_INST:sydney&tab=Everything&search_scope=MyInst_and_CI&mode=basic&displayMode=full&bulkSize=10&highlight=true&dum=true&query=any,contains,Craft%20%20J.%20%20%26%20Gordon%20%20C.%20(2019).%C2%A0Understanding%20pathophysiology%20%C2%A03rd%20Australian%20and%20New%20Zealand%20edition%20St.%20Louis%20%20Missouri:%20Elsevie&displayField=all&q=Craft,%20J.,%20%26%20Gordon,%20C.%20(2019).%C2%A0Understanding%20pathophysiology,%C2%A03rd%20Australian%20and%20New%20Zealand%20edition,St.%20Louis,%20Missouri:%20Elsevier
NURS5012 Assessment & Clinical Judgement
In this assessment you are required to complete a comprehensive and focused patient assessment and develop a report on the assessment findings. Students are to identify a patient in their clinical specialty area that is suitable for a case study and undertake comprehensive patient assessment. Informed patient (verbal) consent should be obtained where possible, prior to the comprehensive patient assessment andall subsequent documentation pertaining to the assessment must be de-identified.
Format:Case study report
Length:Maximum2,500 words
Due: 20/05/23
Note: youcannot use pulmonary embolismfor Assessment 2 as its provided in the example.
Pleaserefer to the marking criteria rubricbelow when preparing this assessment to understand how marks are earned
The case study report consists of 2 parts:
Part A: Comprehensive clinical assessment(not included in word count)
Perform a comprehensive patient clinical assessment approach that is appropriate for your clinical setting, and the patients clinical condition. Use thebiopsychosocial comprehensive clinical assessment reporting guidelinesDownload biopsychosocial comprehensive clinical assessment reporting guidelinesas a structure for your report for Part A.
Part B: Case study report(2,500 words maximum, with suggested section word counts below)
Using the data obtained from your comprehensive clinical assessment of the patient, construct a case study report. You should present the case study report as outlined below with the four headings for each section to clearly distinguish the different aspects. References need to be included to support your work. Your case study should address all following questions:
1a. WHAT IS GOING ON HERE? (approx 750 words)
Patients presentation What did the person present with? (one paragraph)
Evident clinical manifestations Signs and symptoms.
Please include both observed mental and physical health signs and symptoms.
1b. PATHOPHYSIOLOGY OF CLINICAL MANIFESTATION (approx 750 words)
Pickone(1) aspect of the patients pathophysiological presentation.For example, the patient may have the following clinical manifestation:
purulent sputum,
elevated blood glucose levels,
changes in heart rate or rhythm,
anxiety,
increased white cell count
How did the selected problem arise in pathophysiological terms?
PLEASE NOTE: You need todescribe the pathophysiological process leading to the clinical manifestation,nota general explanation ofdisease processes(that is, for example, asthma or diabetes).
Your textbook is available free online through the university library catalogue to assist with pathophysiology:Craft, J., & Gordon, C. (2019).Understanding pathophysiology,3rd Australian and New Zealand edition, St. Louis, Missouri: ElsevierLinks to an external site.
WHAT ELSE DO I NEED TO KNOW? (approx 500 words)
What further information is required at this point?
What other assessments/investigations need to be performed or recommended in order to complete the clinical picture?
What aspects of the patients health history need further information to inform the comprehensive clinical assessment?
WHAT DOES THIS ALL MEAN? (500 words max)
Overall clinical impression based on the above, describe what you consider the "larger picture" is in relation to the patient's biopsychosocial needs (consider and include both mental and physical considerations).
NURS5012 Assessment 2
NURS5012 Assessment 2
Criteria Ratings Pts
Use of reporting guidelines
view longer description 25 to >22 pts
High distinction
Uses reporting guidelines for exceptional level of assessment & integration of biopsychosocial factors
22 to >19 pts
Distinction
Uses reporting guidelines for superior level of assessment & integration of biopsychosocial factors
19 to >16 pts
Credit
Uses reporting guidelines to meet a sound level of assessment and integration of biopsychosocial factors
16 to >13 pts
Pass
Uses reporting guidelines to meet an acceptable level of assessment. Not all areas developed to full potential
13 to >0 pts
UnsatistactoryNo evidence of guideline use. Does not reflect a comprehensive biopsychosocial approach to assessment / 25 pts
Pathophysiology
view longer description 20 to >17 pts
High distinction
Sophisticated explanation of the pathophysiology behind chosen clinical manifestation
17 to >15 pts
Distinction
Superior explanation of the pathophysiology behind one chosen clinical manifestation
15 to >12 pts
Credit
Sound explanation of the pathophysiology behind one chosen clinical manifestation
12 to >9 pts
Pass
Acceptable explanation of the pathophysiology behind chosen clinical manifestation
9 to >0 pts
Unsatisfactory
Unable to clearly articulate the pathophysiology behind one clinical manifestation / 20 pts
Further assessment
view longer description 25 to >22 pts
High distinction
Identifies key assessments, investigations & history required to an exceptional level
22 to >19 pts
Distinction
Identifies key assessments, investigations & history required to a superior level.
19 to >16 pts
Credit
Identifies key assessments, investigations & history required to a sound level. Includes most of the important elements
16 to >13 pts
Pass
Identifies key assessments, tests & history required to an acceptable level. Some important elements may be missing
13 to >0 pts
Unsatisfactory
Not able to identify the minimum key assessments, investigations and history required to complete the clinical picture / 25 pts
Clinical judgement
view longer description 20 to >17 pts
High distinction
Outstanding critical appraisal of findings to inform sophisticated clinical judgement
17 to >15 pts
Distinction
Advanced critical appraisal of findings to inform superior clinical judgement
15 to >12 pts
Credit
Comprehensive critical appraisal of findings to inform sound clinical judgement
12 to >10 pts
Pass
Predominantly descriptive, minimal appraisal of findings to inform clinical judgement
10 to >0 pts
Unsatisfactory
Unable to critically appraise assessment findings to inform clinical judgement / 20 pts
Writing & referencing
view longer description 10 to >9 pts
High distinction
Outstanding level of scholarship. No typos or grammatical errors. Synthesises & communicates ideas into a sophisticated argument
9 to >7 pts
Distinction
High level of scholarship. Rare typographical or grammatical errors. Can synthesise & communicate ideas into a cohesive argument. APA7 adhered to
7 to >5 pts
Credit
Sound level of scholarship. A few typographical or grammatical errors. Logical flow of ideas. APA7 mostly adhered to
5 to >4 pts
Pass
Basic level of scholarship. Frequent grammatical errors. Ideas mostly logical. Referencing acceptable, may be formatting errors
4 to >0 pts
Unsatisfactory
Poor level of scholarship. Illogical flow of ideas. Does not demonstrate referencing conventions / 10 pts
Total Points: 100
