NUR-634 Topic 4: sample paper, in real form

Focused Cardiovascular Assessment and Differential Diagnosis: Exertional Chest Pressure in a 58-Year-Old Man

[Author Name]

College of Nursing and Health Care Professions, Grand Canyon University

NUR-634 Advanced Health Assessment and Diagnostic Reasoning

Topic 4 Assignment

[Faculty Name]

August 11, 2026

Composite case written as a model document. No real patient, practice or clinician is described.

Focused History

Reason for the visit, in the patient's own words: 'When I push the mower up the slope my chest gets tight like a belt, and it lets go when I stop.' The patient is a 58-year-old man seen in a family practice clinic for pressure across the middle of his chest that began about three months ago. He describes a heavy squeezing sensation behind the breastbone, not sharp and not stabbing, rated 5 out of 10 at its worst. It spreads to the left shoulder and the angle of the jaw in about half of the episodes. Episodes come three to four times in a seven-day span and always during exertion: two flights of stairs, carrying groceries from the car, or yard work in warm weather. Rest ends the pressure within five minutes.

History, medications and risk profile. Hypertension was diagnosed nine years ago and is treated with lisinopril 20 mg daily. A lipid panel four months ago showed total cholesterol 236 mg/dL, LDL cholesterol 158 mg/dL, HDL cholesterol 38 mg/dL and triglycerides 190 mg/dL, with hemoglobin A1C at 5.9 percent. He takes no statin, having stopped one two years ago for muscle aching he never reported. He has smoked half a pack daily since age 18, roughly 20 pack-years, and drinks two beers most evenings. His father had a myocardial infarction at 61 and his brother received a coronary stent at 57. He supervises a warehouse, sleeps six hours a night and has gained 14 pounds in two years.

Targeted review of systems, chosen for the differentials in play. Cardiovascular: reports the exertional pressure described above; denies rest pain, syncope, palpitations, orthopnea and ankle swelling. Respiratory: denies cough, hemoptysis, pleuritic pain and wheeze; reports mild breathlessness that arrives with the chest pressure and leaves with it. Gastrointestinal: reports occasional heartburn after late meals, relieved by an antacid, never brought on by walking and never radiating to the jaw. Musculoskeletal: denies recent lifting injury, fall or new repetitive work. Psychiatric: denies panic episodes and states that the pressure has never started while he was sitting still. Each denial here belongs to a diagnosis the history raised, so the negatives carry as much weight as the positives.

Focused Examination

Vital signs and general appearance. Blood pressure 148/88 mmHg in the right arm and 146/86 mmHg in the left, seated, with an appropriately sized cuff after five minutes of rest; heart rate 78 and regular; respirations 16 and unlabored; temperature 36.8 degrees Celsius; oxygen saturation 97 percent on room air. Height 5 feet 10 inches, weight 219 pounds, body mass index 31.4. He is alert and comfortable at rest, speaks in full sentences, and shifts position freely without guarding the chest. Skin is warm and dry with no diaphoresis and no pallor. Technique follows the standard advanced practice sequence, with the reading taken in both arms before it is recorded (Jarvis & Eckhardt, 2024).

Cardiovascular examination. Jugular venous pulsation is visible 3 cm above the sternal angle with the head of the table at 45 degrees. Carotid upstrokes are brisk and symmetric with no bruit on either side. The point of maximal impulse is palpable in the fifth intercostal space at the midclavicular line, roughly 2 cm across, without heave or thrill. Auscultation gives a regular rate and rhythm with a soft S4 at the apex, heard best with the bell in the left lateral position; S1 and S2 are normal in intensity and no murmur or rub is heard at any site. Radial, femoral, posterior tibial and dorsalis pedis pulses are 2+ and symmetric, with no peripheral edema and no calf tenderness.

Pulmonary, chest wall and abdominal findings. The chest expands symmetrically, percussion is resonant in all fields, and breath sounds are clear bilaterally with no crackles or wheezes. Firm palpation over the costochondral joints and the left sternal border reproduced no discomfort at all, which is the finding that matters most for the chest wall differential. Shoulder and thoracic spine movement did not reproduce the symptom either. The abdomen is soft with normal bowel sounds, no epigastric tenderness and no abdominal bruit. A resting 12-lead electrocardiogram taken in the clinic shows normal sinus rhythm at 76 with normal intervals and no ST segment or T wave change; the tracing is filed with the note as an objective finding rather than as an interpretation of the case.

Diagnostic Reasoning and Differential

Reasoning starts with pretest probability rather than with a list. A man of 58 with substernal pressure that is brought on by exertion, relieved by rest and reproducible at a consistent workload sits in the high probability range for obstructive coronary disease before any test is ordered, and current guidance asks clinicians to call such pain cardiac rather than atypical, because the older label carried no diagnostic meaning and delayed care (Gulati et al., 2021). Four risk factors are already documented: untreated dyslipidemia, 20 pack-years of smoking, blood pressure in the stage 2 range today, and a first degree relative with early coronary disease. The history and the examination point the same way, which is the condition under which a focused write-up can defend a leading diagnosis.

Competing diagnoses are then held against the same data, built outward from the presenting symptom rather than recited from a memorized list (Dains et al., 2020). Gastroesophageal reflux disease is plausible given the reported heartburn, but that heartburn follows late meals rather than exertion, answers to an antacid and never radiates to the jaw, so it explains a second symptom and not the presenting one. Costochondritis and other chest wall pain fall on the examination, since nothing on palpation or thoracic movement reproduced the discomfort. Aortic stenosis can present with exertional chest pressure and stays on the list until echocardiography settles it, though brisk symmetric carotid upstrokes and the absence of a systolic murmur make it unlikely. Panic disorder does not fit a symptom that has never appeared at rest. Anemia and thyrotoxicosis remain low probability contributors that laboratory work will exclude.

Two boundaries belong in the record, set against a base rate in which coronary disease remains the leading cause of death among men in the United States (Centers for Disease Control and Prevention, 2024). First, the pattern is stable rather than accelerating: the same workload has produced the same pressure for three months, episodes have not lengthened, and there is no rest pain, which separates this presentation from an acute coronary syndrome. Second, a normal resting electrocardiogram does not lower the probability in a patient who is free of symptoms while the tracing runs, and writing that sentence into the note stops a later reader from treating a normal tracing as reassurance. Naming what the data cannot settle is part of the reasoning rather than an admission of weakness in it.

Working Diagnosis and What the Record Carries Forward

Working diagnosis: chronic stable angina pectoris at high pretest probability, with aortic stenosis and gastroesophageal reflux disease retained as active differentials. The supporting evidence is gathered in one place so that a reviewer does not have to reassemble it: exertional substernal pressure with jaw and shoulder radiation, reproducible at two flights of stairs, resolving within five minutes of rest, in a 58-year-old man with four documented risk factors, an S4 at the apex, no reproducible chest wall pain and no murmur. The documented pathway follows the guideline sequence for stable chest pain, including risk factor laboratory work, echocardiography, anatomic or functional testing selected with the patient, and cardiology referral (Gulati et al., 2021; Arnett et al., 2019). An LDL cholesterol of 158 mg/dL at this risk level also puts lipid lowering therapy and the earlier muscle aching back on the agenda (Grundy et al., 2019).

The record then carries the person, not only the problem. His own description of the symptom is preserved in quotation marks, because the words a patient chooses are evidence and because a chart that keeps them treats him as a person rather than a collection of findings. Two practical facts he raised are documented as well: he stopped a statin for muscle aching he never reported, and he is worried about missing shifts if testing is scheduled during the day. Both belong in the note because both will shape whether the plan is ever carried out. Safety information given during the visit is recorded in specific terms, including which change in the pattern would make the situation urgent.

References

Arnett, D. K., Blumenthal, R. S., Albert, M. A., Buroker, A. B., Goldberger, Z. D., Hahn, E. J., Himmelfarb, C. D., Khera, A., Lloyd-Jones, D., McEvoy, J. W., Michos, E. D., Miedema, M. D., Munoz, D., Smith, S. C., Virani, S. S., Williams, K. A., Yeboah, J., & Ziaeian, B. (2019). 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease. Circulation, 140(11), e596-e646.

Centers for Disease Control and Prevention. (2024). Heart disease facts. U.S. Department of Health and Human Services. https://www.cdc.gov/heart-disease/

Dains, J. E., Baumann, L. C., & Scheibel, P. (2020). Advanced health assessment and clinical diagnosis in primary care (6th ed.). Elsevier.

Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun, L. T., de Ferranti, S., Faiella-Tommasino, J., Forman, D. E., Goldberg, R., Heidenreich, P. A., Hlatky, M. A., Jones, D. W., Lloyd-Jones, D., Lopez-Pajares, N., Ndumele, C. E., Orringer, C. E., Peralta, C. A., ... Yeboah, J. (2019). 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol. Circulation, 139(25), e1082-e1143.

Gulati, M., Levy, P. D., Mukherjee, D., Amsterdam, E., Bhatt, D. L., Birtcher, K. K., Blankstein, R., Boyd, J., Bullock-Palmer, R. P., Conejo, T., Diercks, D. B., Gentile, F., Greenwood, J. P., Hess, E. P., Hollenberg, S. M., Jaber, W. A., Jneid, H., Joglar, J. A., Morrow, D. A., ... Shaw, L. J. (2021). 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain. Circulation, 144(22), e368-e454.

Jarvis, C., & Eckhardt, A. L. (2024). Physical examination and health assessment (9th ed.). Elsevier.