Sharp Chest Pain Two Days After a Fourteen-Hour Flight: A Focused Cardiovascular and Respiratory Assessment of a 26-Year-Old Woman
[Student Name]
University of Phoenix
NSG/523: Advanced Health Assessment
Week 4 Assignment
[Instructor Name]
[Date]
Composite patient written as a model document. No real patient, clinician or practice is described.
Subjective
The patient is a composite 26-year-old doctoral student in chemistry, seen at a nurse practitioner led urgent care clinic for chest pain. Yesterday afternoon she developed sharp pain in the left side of her chest, below the breast and toward the back, that is worse when she breathes in deeply or coughs and eases when she takes shallow breaths. She rates it 6 out of 10. It is not affected by lying down or leaning forward, and pressing on her chest does not reproduce it. She has felt short of breath walking up the stairs to her apartment since this morning. Two days ago she returned from a 14-hour flight from Seoul, during which she slept in her seat and walked the aisle only once.
She mentioned the flight only as the reason she was tired, and she did not mention that her left calf had felt tight since she landed until she was asked about her legs. She denies fever, chills, productive cough, hemoptysis, palpitations, fainting, recent illness, chest trauma and heavy lifting.
Past history: no prior blood clots, heart disease, lung disease or cancer. She has taken a combined estrogen-progestin oral contraceptive for six years. She does not smoke or vape and drinks alcohol socially. Her mother had a blood clot in the leg after knee surgery; there is no known inherited clotting disorder in the family.
Objective
Vital signs: temperature 37.4 C, blood pressure 118/74 mm Hg, pulse 104 and regular, respirations 20, oxygen saturation 96% on room air, weight 61 kg.
General: alert, speaking in full sentences, mildly anxious, splinting her left side with deep breaths.
Neck: jugular venous pressure not elevated; trachea midline.
Chest and lungs: symmetric chest wall movement with slightly reduced expansion on the left because of pain. No tenderness of the ribs, costochondral junctions or chest wall. Percussion resonant throughout. Breath sounds vesicular and equal in both lungs; no crackles, wheezes or pleural rub. Tactile fremitus symmetric.
Heart: rate 104, rhythm regular. Apical impulse small and localized in the normal position, not displaced. S1 and S2 normal, with a physiologically split S2 on inspiration and no loud pulmonic component. No murmurs, gallops or friction rub, including with the patient leaning forward.
Peripheral vascular: pulses full and symmetric at the wrists, groins and both feet. The left calf measures 36.5 cm in circumference 10 cm below the tibial tuberosity, compared with 34.5 cm on the right, and there is tenderness along the deep veins of the left calf and mild pitting edema at the left ankle. No redness or superficial cord. Skin warm with normal capillary refill.
Advanced examination texts place the peripheral vascular examination alongside the cardiac and pulmonary examinations because venous disease in the legs is part of the cardiopulmonary picture (Bickley et al., 2021).
Reading the Risk Factors Through Virchow's Triad
The history and examination make more sense when organized by the three conditions that promote venous thrombosis: stasis of blood flow, injury to the vessel wall and a tendency to clot. Stasis came from fourteen hours seated in a cramped seat with little walking, the classic setting for travel-related thrombosis. A hypercoagulable tendency came from six years of estrogen-containing contraception and possibly from an inherited factor, suggested by her mother's clot after surgery. Vessel injury is the only element without clear support; she had no trauma or surgery. Two of the three conditions are strongly present, and together they explain why a healthy 26-year-old could develop a clot. The triad also shapes the plan. If a clot is confirmed, stopping estrogen removes one modifiable cause, and the family history raises the question of testing for an inherited thrombophilia, a decision best made by the treating team after the acute event rather than during it.
Assessment
Pulmonary embolism with a probable left leg deep vein thrombosis is the leading concern. Wells et al. (2000) developed a clinical score that assigns 3 points for clinical signs of deep vein thrombosis, 3 points when pulmonary embolism is the most likely diagnosis, 1.5 points for a heart rate above 100 and additional points for prior clot, recent immobilization or surgery, hemoptysis and cancer. This patient scores 3 for the calf swelling, tenderness and edema, 3 because no alternative explains her findings as well and 1.5 for a pulse of 104, a total of 7.5, which places her in the category in which pulmonary embolism is likely.
The pulmonary embolism rule-out criteria cannot be used to exclude embolism here, because they apply only when every criterion is negative, and her heart rate, leg swelling and estrogen use are each positive (Kline et al., 2004). Current guidelines recommend that patients with a high or likely clinical probability proceed directly to imaging, usually computed tomography pulmonary angiography, rather than rely on a D-dimer to rule out embolism (Konstantinides et al., 2020).
The alternatives are ranked by the recorded findings. Spontaneous pneumothorax can cause sudden pleuritic pain in young adults, but equal breath sounds, resonant percussion and a midline trachea make it unlikely. Pneumonia is less likely with no fever above 37.4 C, no productive cough and no crackles. Pericarditis is less likely because the pain is not positional and there is no friction rub. Costochondritis is unlikely because pressure on the chest wall does not reproduce the pain. Anxiety may contribute to her distress but cannot explain a fast heart rate, a lower oxygen saturation and an asymmetric, tender calf.
Plan
Because pulmonary embolism is likely, she is sent by ambulance to the emergency department for computed tomography pulmonary angiography and lower extremity venous ultrasound, with a call to the emergency physician giving the history, examination and Wells score. The nurse practitioner explains the reason to the patient calmly and asks her not to drive. If the diagnosis is confirmed, anticoagulation will be started, and the combined oral contraceptive will be stopped and an alternative method discussed, since estrogen increases the risk of venous thrombosis.
Communication and Follow-Up
The patient was frightened when she heard the words blood clot. The nurse practitioner explained that the tests would give a clear answer that day, that treatment is effective and that sending her for testing was a precaution based on specific findings. With her permission, the clinic called her roommate to meet her at the hospital. A follow-up visit was scheduled for one week after discharge to review the results, her anticoagulation and her contraception.
Conclusion
A young woman who looked well and whose pain could easily have been attributed to a strained muscle had a history of a long flight and estrogen use, a fast heart rate, a lower oxygen saturation and a swollen, tender calf. A focused cardiovascular and respiratory examination that included the legs, and a validated score calculated from the recorded findings, placed pulmonary embolism at the top of the differential and directed her to same-day imaging instead of reassurance.
References
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.
Kline, J. A., Mitchell, A. M., Kabrhel, C., Richman, P. B., & Courtney, D. M. (2004). Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. Journal of Thrombosis and Haemostasis, 2(8), 1247-1255. https://doi.org/10.1111/j.1538-7836.2004.00790.x
Konstantinides, S. V., Meyer, G., Becattini, C., Bueno, H., Geersing, G.-J., Harjola, V.-P., Huisman, M. V., Humbert, M., Jennings, C. S., Jimenez, D., Kucher, N., Lang, I. M., Lankeit, M., Lorusso, R., Mazzolai, L., Meneveau, N., Ni Ainle, F., Prandoni, P., Pruszczyk, P., ... Pepke-Zaba, J. (2020). 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). European Heart Journal, 41(4), 543-603. https://doi.org/10.1093/eurheartj/ehz405
Wells, P. S., Anderson, D. R., Rodger, M., Ginsberg, J. S., Kearon, C., Gent, M., Turpie, A. G. G., Bormanis, J., Weitz, J., Chamberlain, M., Bowie, D., Barnes, D., & Hirsh, J. (2000). Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: Increasing the models utility with the SimpliRED D-dimer. Thrombosis and Haemostasis, 83(3), 416-420. https://doi.org/10.1055/s-0037-1613830
How this NSG 523 Week 4 example is structured
The University of Phoenix library guide for NSG/523 lists Week 4 as Cardiovascular and Respiratory Assessments. The write-up takes a young, well-appearing patient on purpose, because the danger in chest pain assessment is dismissing a serious cause in someone who looks healthy. The history gathers the risk factors, the examination covers heart, lungs and legs with the pertinent negatives each alternative requires, and the assessment turns the findings into a validated probability score before choosing the next step. Students search this week as NSG 523 Week 4, NSG523 Wk 4 or NSG/523 Wk 4; all three are the same assignment.
NSG/523 Week 4 questions, answered
What does NSG/523 Week 4 usually ask for?
The University of Phoenix library guide for NSG/523 lists Week 4 as cardiovascular and respiratory assessments. Many sections ask for a focused history and examination write-up on a cardiopulmonary complaint, with a differential diagnosis supported by the findings. Your own instructions decide the exact form and length.
Why does the write-up examine the legs in a chest pain case?
Because pulmonary embolism usually starts as a deep vein thrombosis in the legs, and signs of a clot there change the probability of embolism. A cardiovascular assessment includes the peripheral vascular examination for this reason.
What is the difference between the Wells score and the PERC rule?
The Wells score estimates how likely pulmonary embolism is. The PERC rule identifies low-risk patients who need no further testing, but only if all eight criteria are negative. A patient taking estrogen, like the one in the sample, cannot be ruled out with PERC.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official University of Phoenix document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.