Assessment Focused Extended Text

Focused Assessment

Introduction

Shadow health assessments aim to examine assessment skills, history taking skills, and clinical reasoning. The focused assessment in this assignment involves Brian Foster, a man who presented with complaints about chest pain. The purpose of this paper is to review the learning experience through assessment, data collection, and documentation for this patient.

Focus of the Assessment

The assessment focuses on Brian Foster, a patient who reported a chest pain that began approximately a month ago. The pain worsens with activity, movement, work, or overeating. The current chest pain occurred 3 days ago after overeating. The pain is located at the center of the chest, and the patient described it as tight and uncomfortable. A focused assessment will help to identify the possible health problem presented by the chest pain. Assessment Focused Extended Text

Subjective Component

Mr. Foster reported a recurring chest pain that began about a month ago. Activity, movement, overeating, and work aggravate the chest pain. The patient reported that the pain lasts for about a few minutes, and then goes away after rest. He was anxious and worried because the chest pain is recurring and over the past one  month, he has had three episodes of chest pain. Mr. Foster describes the pain as uncomfortable and tight.

The patient reported a history of hypertension and hyperlipidemia and his medications to include Lisinopril 10 mg po daily; Atenolol 25 mg; Coumadin 2.5 mg po daily; Atorvastatin 20 mg po daily; and Fish Oil 1 capsule po daily. The allergies include codeine allergy. Mr. Foster reported that the father had a history of hypertension, hyperlipemia, and obesity. The father died of colon cancer. The mother and the sister have diabetes and hypertension, while his daughter has asthma.

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Mr. Foster is not physically active and also reported a high intake of red meat. He is a non-smoker but consumes alcohol moderately. He reported weight gain over the past few years. He lives with his wife and has two adult children. He is an engineer. His vaccinations are up-to-date.

For the ROS, the patient appeared well and not in pain. He denied ear pain, eye problem, nose problem, sore throat, swallowing difficulties, or neck pain. He reported chest pain but denied cough or wheezing. The patient denied increased heart rate, breathing difficulties, radiation, and palpitations. He also denied abdominal pain, nausea, vomiting, diarrhea, coughing, heartburn, fatigue, dizziness, lightheadedness, depression, or sleep problems.

Objective Component

The patient’s vital signs are RR: 19, Temp 36.7, HR 109, BP 146/90, Pulse Ox 98%, Weight 197lbs, BMI 27.5. Mr. Foster appears well, in a pleasant mood, in good health, and oriented to time, place, and situation.

HEENT: The head is normocephalic; intact gag reflex; moist nasal and oral mucosa; tonsils 2+ bilaterally; smooth thyroid; no goiter; bruit in the right carotid artery +ve thrill; no jugular distention; left carotid artery no bruit.

Respiratory: Normal breath souths; fine crackles in posterior bases of both lungs; clear lung sounds; fine crackles. Cardiovascular: No ST changes; sinus rhythm normal; capillary refill less < three seconds; carotid bruit in the right side; right carotid pulse thrill 3+.

Neurological: Oriented to time, place, and situation; PERRLA +3; brisk bilaterally. Musculoskeletal: No joint or muscle pain; no limited movement; full range of movements within all joints Assessment Focused Extended Text

Evidence to Support Clinical Reasoning

Collecting both objective and subjective data, as well as performing the physical assessment is essential in coming up with a differential diagnosis, and making the final diagnosis. From the collected subjective and objective data, Mr. Foster’s chest pain could be attributable to vessel occlusion and artery disease. The patient reported that the pain at the center of the chest denied any radiation or increased heartbeat. The physical assessment revealed that the presence of a carotid bruit in the right side and right carotid pulse thrill 3+. These findings were used to inform the differential diagnosis (Ford et al., 2018). Obesity and lack of adequate physical activities may also be attributable to chest pain. Additionally, the diet for the patient consists of fast foods, red meat and also takes alcohol moderately; this is a risk factor to the patient’s health, considering his history of hypertension and hyperlipemia (Pallazola et al., 2019).

List of Problems

  • Angina basal pectoris
  • Bilateral Basal crackles
  • Inactive lifestyle

Diagnosis

Angina basal pectoris: The diagnosis is informed by the subjective data and the findings from the physical assessment. Angina pectoris is characterized by chest pain or discomfort because of coronary heart disease (Lanza, 2019). Angina pectoris occurs when the heart muscle does not get an adequate supply of blood.

Plan of Care

Mr. Foster will undergo an echocardiogram and stress test to examine for coronary heart disease. The echocardiogram will be used to evaluate the function and structures of the heart, while the stress test will examine how well the heart works, when under stress.

For the treatment, Mr. Foster should continue taking his current medications that include Lipitor for hyperlipemia, Lopressor for hypertension, and omega-3 fish oil for managing heart disease. As per the findings, the patient will be started on a new medication to manage the chest pain and treat the possible coronary heart disease (Boden et al., 2015).

Mr. Foster will be educated regarding the importance of closely monitoring his lipid levels, blood pressure, and cardiac markets. He will also be educated on the link between weight and diseases such as cardiovascular diseases. Mr. Foster will therefore be advised to be physically active through appropriate exercises and consider diet changes that include low calories and minimal intake of red meat (Yu et al., 2018). Assessment Focused Extended Text

Conclusion

The focused assessment involved Brian Foster, a male who presented with complaints about chest pain. The objective data was collected by interviewing the patient, while the subjective data was collected by performing the physical examination. The physical examination focused on the cardiovascular and respiratory system because the chief complaint was chest pain. From the collected data, the possible diagnosis is angina basal pectoris. The patient should undergo an echocardiogram and stress test to confirm or rule out other diagnoses and examine how well the heart is functioning.

References

Boden, W. E., Padala, S. K., Cabral, K. P., Buschmann, I. R., & Sidhu, M. S. (2015). Role of short-acting nitroglycerin in the management of ischemic heart disease. Drug design, development, and therapy, 9, 4793–4805. https://doi.org/10.2147/DDDT.S79116

Ford, T. J., Corcoran, D., & Berry, C. (2018). Stable coronary syndromes: pathophysiology, diagnostic advances, and therapeutic need. Heart (British Cardiac Society), 104(4), 284–292. https://doi.org/10.1136/heartjnl-2017-311446

Lanza G. A. (2019). Diagnostic Approach to Patients with Stable Angina and No Obstructive Coronary Arteries. European Cardiology, 14(2), 97–102. https://doi.org/10.15420/ecr.2019.22.2

Pallazola, V. A., Davis, D. M., Whelton, S. P., Cardoso, R., Latina, J. M., Michos, E. D., Sarkar, S., Blumenthal, R. S., Arnett, D. K., Stone, N. J., & Welty, F. K. (2019). A Clinician’s Guide to Healthy Eating for Cardiovascular Disease Prevention. Mayo Clinic proceedings. Innovations, quality & outcomes, 3(3), 251–267. https://doi.org/10.1016/j.mayocpiqo.2019.05.001

Yu, E., Malik, V. S., & Hu, F. B. (2018). Cardiovascular Disease Prevention by Diet Modification: JACC Health Promotion Series. Journal of the American College of Cardiology, 72(8), 914–926. https://doi.org/10.1016/j.jacc.2018.02.085. Assessment Focused Extended Text