Virtual Simulation Chest Pain
Introduction
Brian Foster is a male who is complaining of chest pain. MR. Foster explains that the chest pain has lasted for a month continuously. According to him, the pain resembles heartburn pain, but it lasts for several minutes before it disappears. He also reported that the pain mainly occurs at night where he feels his chest is tighter than normal. Also, he experiences similar pains any time he is involved in tedious physical activity. He also adds that the pain disappears when he rests or lays still. With this information, the past and present history of MR. Foster will be used to determine the differential prognoses that will guide the plan of care relevant for Mr. Foster case.
Focus of the Assessment
From the information provided by Mr. Foster, I will focus on the cardiovascular system. He has been receiving medication for high blood pressure, and the chest pains can be as a result of hypertension. His family members have at one time suffered from hypertension and hyperlipidemia which can also be the cause of chest pains experienced by Brian Foster. Assessment of his cholesterol levels will be done which can also be exerting the pains to the chest. The acid levels of Mr. Foster will be assessed which can be resulting in chest pains at night. Ultimately, a physical assessment will be done to determine the exact problem affecting Brian.
Focused Health History
The provided information revealed that Mr. Foster has been suffering from high blood pressure which is evident from the medication given. He is also a victim of hyperlipidemia as he has been receiving medication to control cholesterol. Mr. Foster has not undergone any surgical procedure despite being diagnosed with high blood pressure and high cholesterol. The family of Mr. Foster has a history of hyperlipidemia and obesity which were in the medical history of his father. His mother also suffers from hypertension and diabetes-2, and his sister also has a medical history of type-2 diabetes. Mr. Foster daughter have asthma. Although he does not consume tobacco, he is a heavy alcohol drinker, and he was advised to reduce the alcohol intake to 1 or 2 bottles in a day. I would like to know of Mr. Foster has been tested for acid reflux.
Physical Examination
Mr. Foster has a good appearance with no cognitive deficiency evident from complete information given. His skin is dry and warm and has no signs of tenting. He is not gloomy at sight. He has no symptoms of neck pain, and the jugular vein is in its normal position. JVD is not in its normal location as it is above the sternal angle. A bruit is seen on the right carotid artery, but the left artery is normal. The point of maximum impulse is displaced literally. Lung sounds are normal. Mr. Foster had varicosity in his bilateral lower extremities and cyanosis. The examination revealed that chest pains occur only with physical activity. The tools used to assess the patient included a thermometer, ECG, stress tests and stethoscope.
Documented Evidence
From the information given by Mr. Foster, chest pains can be assumed to be caused by hypertension, esophagitis, coronary heart disease or high levels of cholesterol. Though the tests from the abdomen revealed normal results, he can be suffering from acid reflux that was not tested. Acid reflux is believed to cause chest pains, especially during the nights. Previous studies also support that chest pains at night can be as a result of coronary heart disease of esophagitis. The results from the ECG revealed some abnormality in varicose veins. The results of his weight revealed his BMI is above the normal which means he is obese. Putting all these factors in consideration, the differential diagnoses for Mr. Foster can be assumed to include obesity, hyperlipidemia, acid reflux, hypertension and coronary heart diseases.
Plan of Care
Due to his current condition, Mr. Foster should continue with his current course of medication as e proves to be suffering from the same diseases diagnosed in the previous test. The physical assessment revealed that he is obese; thus, medication for obesity should be initiated as well as measures to reduce his weight. Mr. Foster should be put on a course of nitroglycerine which will help manage the chest pain episodes. Due to his above normal BMI, he will be enrolled in counselling classes where he will be advised on different ways to manage his weight by diet, exercise and maybe proper medications. Follow-up sessions will be put in place to monitor his lipids level and cardiac activity. Tests should be taken on acid levels.
Conclusion
Mr. Foster was informative, and this made it easy for my assessment. He cooperated in all stages of the assessment and from the information given, preferential diagnoses were determined. He expressed his willingness to participate in his treatment and well-being.