| Course | NUR 560 Advanced Health Assessment and Clinical Reasoning |
|---|---|
| Module | Module 2 |
| Paper type | Focused assessment with problem representation and ranked differential |
| Length | About 1,090 words, 6 pages |
| Format | APA 7 student paper |
| School | Southern New Hampshire University |
| Program | MSN |
| Updated | September 2026 |
Free sample paper for NUR 560 Module 2
Pressure on the Stairs: A Focused Chest Pain Assessment and Ranked Differential in a 58-Year-Old
[Student Name]
Southern New Hampshire University
NUR 560: Advanced Health Assessment and Clinical Reasoning
Focused Assessment
[Instructor Name]
[Date]
The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.
Pressure on the Stairs: A Focused Chest Pain Assessment and Ranked Differential in a 58-Year-Old
Adults bring chest pain to urgent care constantly, and far more often than not the heart is not the cause. The challenge is to identify the minority of patients with a dangerous cause without testing everyone for everything. National guidance recommends a structured approach that uses the history, electrocardiogram and troponin together with validated risk tools (Gulati et al., 2021). Here that approach is worked through for one composite patient, a man of 58. It argues that his exertional pressure, risk factors and HEART score place acute coronary syndrome at the top of a ranked differential despite a normal first troponin, while pulmonary embolism, aortic dissection and pericarditis, though dangerous, are each made unlikely by specific findings.
Focused History and Why Each Question Was Asked
Each question tested a hypothesis. Asked to describe the pain, he said it felt like "a weight" in the center of his chest, spreading to his left arm, coming on twice in two days while climbing the stairs at work and easing after about five minutes of rest; that pattern points to ischemia. Asked whether it hurt to breathe or changed with position, he said no, which argues against pericarditis and pleuritic causes. Asked about tearing pain through to the back, fainting or weakness, he denied all three, making aortic dissection less likely. Asked about leg swelling, recent travel, surgery or coughing blood, he denied all four, lowering the likelihood of pulmonary embolism. Asked about burning after meals or relief with antacids, he reported neither. His risk factors are hypertension, current smoking and high cholesterol; his father had a heart attack at 60.
Focused Examination
The examination was also targeted. Both arms read 148/88 mm Hg, a symmetry that argues against dissection. Pulse was 82 and regular, respiratory rate 16 and oxygen saturation 97%, findings that do not suggest embolism. Heart sounds were normal without a rub or new murmur, lungs were clear and the chest wall was not tender, which lowers the likelihood of pericarditis, heart failure and musculoskeletal pain. The legs showed no swelling or tenderness. His electrocardiogram showed nonspecific repolarization changes without ST elevation, and the first high-sensitivity troponin was within the normal range.
Problem Representation and HEART Score
Problem representation: a 58-year-old man with multiple cardiac risk factors and new, exertional, substernal pressure radiating to the left arm and relieved by rest, with a nonspecific electrocardiogram and an initially normal troponin.
The HEART score estimates the short-term risk of a major adverse cardiac event from five elements, each scored 0 to 2. Table 1 applies it.
Table 1
HEART Score Applied to the Case
| Element | Finding | Points |
|---|---|---|
| History | Highly suspicious: exertional pressure radiating to the arm, relieved by rest | 2 |
| ECG | Nonspecific repolarization changes | 1 |
| Age | 58 (45 to 64) | 1 |
| Risk factors | Hypertension, smoking, high cholesterol, family history (three or more) | 2 |
| Troponin | Within normal limits | 0 |
| Total | 6 |
A score of 6 falls in the intermediate range. In a prospective validation of more than 2,000 emergency department patients with chest pain, major adverse cardiac events within six weeks occurred in 1.7% of those scoring 0 to 3, 16.6% of those scoring 4 to 6 and 50.1% of those scoring 7 to 10 (Backus et al., 2013). He is not a candidate for discharge on the basis of one normal troponin.
Ranked Differential
1. Acute coronary syndrome, most likely unstable angina. For: new exertional pressure, arm radiation, relief with rest, several risk factors, HEART score 6. Against: normal first troponin and no ST elevation, though neither excludes it early.
2. Stable exertional angina. For: the same exertional pattern. Against: symptoms are new within two days, which makes this unstable until proven otherwise.
3. Pulmonary embolism, dangerous and considered. For: chest discomfort and age. Against: normal heart rate and saturation, no leg findings, no risk factors for clotting, and exertional pressure relieved by rest. He cannot be cleared with the PERC rule because he is over 50, one of its criteria (Kline et al., 2004), so if doubt remained a structured pretest probability assessment would guide testing; at present it is low.
4. Aortic dissection, dangerous and considered. For: hypertension. Against: no tearing or back pain, equal arm pressures, no neurological symptoms.
5. Pericarditis. Against: no pleuritic or positional pain, no rub, no diffuse ST elevation.
6. Gastroesophageal reflux or musculoskeletal pain. Against: no relation to meals, no response to antacids, no chest wall tenderness; both remain diagnoses of exclusion here.
Why the Dangerous Diagnoses Were Kept on the List
It would have been easy to list only acute coronary syndrome and move on, since the history is so typical. Keeping pulmonary embolism, aortic dissection and pericarditis on the list, even low down, protects against the premature closure that causes many diagnostic errors. Each of the three can kill quickly, each can mimic ischemic pain and each has a treatment that would be harmful if the wrong diagnosis were assumed: anticoagulation given for a presumed coronary event could be catastrophic in a dissection, for example. That is why the history and examination above deliberately sought the findings that would raise each one, a tearing pain or pressure difference for dissection, leg swelling or hypoxia for embolism, a rub or positional pain for pericarditis, and why their absence is recorded as evidence rather than left unstated. The ranking reflects both likelihood and danger.
Plan and What Would Change the Ranking
He should have a repeat high-sensitivity troponin at the interval the local protocol specifies, continuous monitoring and aspirin if there is no contraindication, with further testing such as stress testing or coronary imaging depending on results, consistent with guidance for intermediate-risk patients (Gulati et al., 2021). A rising troponin would confirm myocardial infarction and move him to urgent cardiology care. New ST changes would do the same. Unexpected tachycardia or hypoxia would raise pulmonary embolism, and sudden severe pain with a pulse difference would raise dissection. Two normal troponins with a low-risk noninvasive test would move stable angina and noncardiac causes up.
Conclusion
A focused, hypothesis-driven history and examination turned this man's chest pain into a clear problem representation: new exertional pressure with cardiac risk factors. His HEART score of 6 places him at intermediate risk, and acute coronary syndrome leads the differential despite a normal first troponin. Pulmonary embolism, dissection and pericarditis were each addressed and made unlikely by specific findings. The plan follows the score, and the list of results that would change it keeps the reasoning open rather than closed.
References
Backus, B. E., Six, A. J., Kelder, J. C., Bosschaert, M. A. R., Mast, E. G., Mosterd, A., Veldkamp, R. F., Wardeh, A. J., Tio, R., Braam, R., Monnink, S. H. J., van Tooren, R., Mast, T. P., van den Akker, F., Cramer, M. J. M., Poldervaart, J. M., Hoes, A. W., & Doevendans, P. A. (2013). A prospective validation of the HEART score for chest pain patients at the emergency department. International Journal of Cardiology, 168(3), 2153-2158. https://doi.org/10.1016/j.ijcard.2013.01.255
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: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 144(22), e368-e454. https://doi.org/10.1161/CIR.0000000000001029
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
What the NUR 560 Module 2 instructions ask for
Focused assessment assignments in NUR 560 usually present a common complaint and ask you to gather focused data, write a problem representation, develop a ranked differential and propose next steps. Prompts often ask you to justify your history and examination choices, apply a validated decision tool where one exists, argue each diagnosis with findings for and against, and identify dangerous diagnoses that must be excluded. Three to five pages in APA 7 is the usual length. Write the reason for each history question and examination step alongside it, because showing that data gathering was hypothesis-driven is one of the criteria graders in this course check most carefully.
How this NUR 560 Module 2 focused assessment example is built
In the sample, a composite 58-year-old man's chest pain is assessed step by step. Each history question and examination finding is linked to the diagnosis it tests, including normal findings that lower the likelihood of dissection, embolism and pericarditis. A one-sentence problem representation follows, and the HEART score is calculated element by element to reach 6, then translated into published six-week event rates. The ranked differential argues six diagnoses with findings for and against, addresses the PERC rule's limits for his age and names the results that would reorder the list. Three real sources, including the 2021 chest pain guideline, support it. A section explains why unlikely but dangerous diagnoses were kept on the list.
Where the NUR 560 Module 2 rubric puts the points
Focused assessments are generally graded on hypothesis-driven data gathering, the quality of the problem representation, correct use of decision tools, the ranking and argument of the differential, attention to dangerous diagnoses, the plan and documentation. The differential is the heaviest criterion: each diagnosis should carry the findings that support it and those that argue against it, drawn from the case. Decision tools earn credit when applied correctly with inputs shown and interpreted in terms of risk. Stating what would change the ranking shows that your reasoning is open, which graders reward because it mirrors how experienced clinicians think under uncertainty. Explaining why a dangerous diagnosis stays on the list, and what would raise it, shows mature reasoning.
NUR 560 Module 2 help: the mistakes that cost points
Chest pain assessments often lose points by listing diagnoses without arguments, by treating a normal troponin or electrocardiogram as ruling out coronary disease, or by misapplying tools such as the PERC rule outside the patients it was designed for. Others omit dangerous diagnoses because they seem unlikely. Justify each question, interpret normal findings as evidence, calculate tools with the inputs shown, rank and argue every diagnosis, address the dangerous ones explicitly and name what would change your mind. Keep the case data consistent throughout. If your case is a different complaint, we can prepare a focused assessment with a ranked differential around it. Record normal findings that argue against dangerous diagnoses, since absence of a finding is evidence too.
Get NUR 560 Module 2 written to your instructions
Send the case, the module prompt and the rubric. A focused assessment with justified data gathering, a problem representation, applied decision tools and a ranked, argued differential is ready in 24 to 48 hours, and the first one is free. The paper above is an original model document written by our desk, not a submitted student paper and not an official Southern New Hampshire University document.
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NUR 560 Module 2 questions, answered
Where can I find a free NUR 560 Module 2 Focused Assessment sample?
The complete assessment on this page is free to read: chest pain in a composite 58-year-old with justified history and examination, a problem representation, a calculated HEART score and a ranked, argued differential.
What is the HEART score?
A chest pain risk tool that scores History, ECG, Age, Risk factors and Troponin from 0 to 2 each; totals of 0 to 3 are low risk, 4 to 6 intermediate and 7 to 10 high.
Does a normal first troponin rule out a heart attack?
No. Troponin can take hours to rise, so patients at intermediate or high risk need repeat testing at the interval the protocol specifies.
When can the PERC rule be used?
Only in patients already judged low risk for pulmonary embolism, and only when every criterion, including age under 50, is met.
How do I write a ranked differential?
List diagnoses in order of likelihood and danger, give findings for and against each from the case and state what result would change the order.