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NR 509 Week 5 iHuman Virtual Patient Encounter Attempt 3628069 - Felipe Garcia

Chamberlain University Nursing NR 509 Advanced Physical Assessment Laci Peterson 9 pages
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History Notecard by Jasmine Kirkland on case Felipe Garcia Use this to collect your thoughts to develop a differential diagnosis list. Step 1: Write symptoms (Sx) you have identified in the appropriate column and row. Step 2: Characterize the symptoms using "OLDCARTS" (ie., Onset, Location, Characteristics...etc) in the HPI section. Step 3: Record your thoughts in the space labeled "What this means". Is the disease acute or chronic? Infectious or other?... Timing/treatments Hx Categories Sx= Sx= Sx= Sx= Sx= Sx= CC Provided Told I have high blood pressure How can I help Need to establish care for elevated you? blood pressure Any other Stomach Burning symptoms? HPI Onset/events Several Years Location Epigastric Region Duration Comes and Goes Characteristics Burning sensation Aggravating Spicy food Reliving taking omperazole Severity Pain level of 2/10 mild What this means Patient is experiencing GERD. Attempt: 3628069 Report generated on 8/10/2025, 11:55:02 PM America/New_York Management Plan by Jasmine Kirkland on case Felipe Garcia Pharmacologic Care: Metoprolol 25 mg BID for HTN Famotidine 20mg qAM for 8 weeks for GERD Tylenol 500mg q 6-8 hours PRN for Pain Ibuprofen 600 mg q 6-8 hours PRN for Pain alternate between both medications Supportive Care: DASH Diet Avoid Spicy Foods Salt Reduction Weight loss Exercise daily at least 30 mins a day Alcohol consumption 1-2 drinks a week Smoking Cessation Patient Education: Educated patient on medications, including indication, proper administration, side effects and symptoms to discontinue. Advised patient to check bp pressure daily and what values are abnormal Importance of adherence to both lifestyles and pharmacologic interventions Recognizing symptoms of hypertensive emergencies Potential side effects and how to monitor for them Educated on possible interactions with other medication, over-the-counter medications Follow-up: Recheck BP in 2 weeks Discussed signs of when to call the clinic or seek emergency treatment. References Carey, R. M., Wright Jr, J. T., Taler, S. J., & Whelton, P. K. (2021). Guideline-driven management of hypertension: An evidence-based update. Circulation Research, 128(7), 827–846. https://doi.org/10.1161/ CIRCRESAHA.121.318083 Electronic Health Record by Jasmine Kirkland on case Felipe Garcia History of Present Illness Category Data entered by Jasmine Kirkland Reason for Encounter "I was told by a nurse that my blood pressure was elevated during a recent health fair" History of present illness Reports today after being informed of elevated blood pressure readings during a recent health screening at a local health fair approximately one week ago. Patient also reports experiencing a burning sensation in the upper abdomen for the past several years. The discomfort comes and goes. He describes the discomfort as a β€œburning” pain located in the epigastric region, occurring mostly after eating spicy meals. He takes omeprazole over-the- counter medications for relief which is successful. Pain level is mild, 2/10. Past Medical History Category Data entered by Jasmine Kirkland Past Medical History Denies chronic illness or previous diagnoses of HTN, Heart Disease, Diabetes and Hyperlipidemia Hospitalizations / Surgeries Hospitalized for R knee surgery. R ACL repair Medications Category Data entered by Jasmine Kirkland Medications Omperazole (Over the counter)

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