Assignment: Peripheral Vascular System
Assignment: Peripheral Vascular System
Assignment: Peripheral Vascular System
Permalink: https://onlinenursingessays.com/assignment-perip…-vascular-system/
SUBJECTIVE DATA:
Chief Complaint (CC): “I have been having some troubling chest pain in my chest for some time now.”
Struggling to Meet Your Deadline?
Get your assignment on Assignment: Peripheral Vascular System done on time by medical experts. Don’t wait – ORDER NOW!
Meet my deadline
History of Present Illness (HPI): A 58-year-old Caucasian male comes to the clinic. The patient reports, “I have been having some troubling chest pain in my chest for some time now.” The patient further reports that he has been having chest pains periodically, particularly when exerting himself in the yard or while overeating. The location of the pain is at the mid sternum region, and he scores it as a 5/10 whenever he experiences it. His description of the pain is “tight and uncomfortable.” The pain does not radiate. The pain does not last for long and disappears upon the patient’s resting. His latest chest pain episode occurred three days ago at a restaurant due to a large dinner. He did not think the pain required urgent attention; however, he demonstrates concern due to the three episodes within the month, and, as such, he needs the heart to be examined. He also states that his legs cramp mildly when engaged in inactivity. He rejects the presence of dyspnea, GERD, indigestion, and heartburn. He states there is no chest pain at the time of assessment.
Medications: The patient has a medical history of using omega three on a daily basis from fish oil, atorvastatin (20 mg) on a daily basis, for high cholesterol for the last one year, occasional use of ibuprofen. The patient takes metoprolol, 100 mg for high blood pressure.
Allergies: The patient confirms some allergies
Past Medical History (PMH): The patient last visited a primary care provider last three months ago. The patient has had treatments for high cholesterol and high blood pressure but reports no incidences of hospitalization.
Past Surgical History (PSH): no past surgical history was reported
Personal/Social History: while the patient denies using tobacco, he agrees that he consumes alcohol moderately, with the patient using two to three alcoholic drinks every week. The patient does not engage in any regular exercise in recent times as the last regular exercise was done the last time two years ago.
Immunization History: No immunization data was presented.
Significant Family History: The late father had obesity, hypertension, and hyperlipidemia, sister has diabetes type 2 and hypertension. Mother had a heart attack.
Review of Systems
General: The patient reports a recent weight gain since the loss of his bike. Denies any sweats, night sweats, chills, fever, and fatigue
Cardiovascular/Peripheral Vascular: no edema, orthopnea, nor chest pain
Respiratory: no pneumonia, dyspnea, hemoptysis, wheezing, and cough
Gastrointestinal: denies ulcers, eating disorders, hepatitis, constipation or
abdominal pain
Musculoskeletal: no fracture, pain or stiffness, joint swelling or back pain
Psychiatric: No suicidal attempts/ideation, sleeping difficulties, anxiety or
depression
OBJECTIVE DATA:
Physical Exam:
Vital signs: BP : 105/78; T: 98.3; P: 117; R:22; Weight: 124lbs; Height: Height 5’
General Survey: The patient is a 58-year-old who demonstrates alertness and is proper orientation. He has clear speech and does not appear to be in any acute distress.
Cardiac: S1, S2, gallops do not have rubs or murmurs. The PMI has a lateral displacement. S3 is appearing at the mitral area.
Peripheral Vascular: He has a carotid bruit on the right side. His JVP appears above the sternal angle at 3cm. He has 3+ thrill at the right carotid. The pulse in the left carotid lacks thrill and has a 2+ expected amplitude. The femoral, radial, and brachial pulses lacked bruit ar 2+. Dorsalis pedis, tibial and popliteal pulses lack thrill at 1+. The capillary refill occurs below 3 seconds at all the four extremities.
Respiratory: The patient breathes quietly and unlabored. His breath sounds showed clarity to auscultation around the RML and the upper lobes. The patient produces fine rales/crackles in the bases of posterior regions of the left and right lungs.
Gastrointestinal: The abdomen is soft, round with a non-tender appearance. All four quadrants produce normoactive sounds. The abdomen lacks bruits. Both palpitations did not show tenderness. Tympany exists throughout the abdomen. The patient’s liver’s length is 7cm and 1 cm at the MCL and below the right costal margin, respectively. The bilateral kidneys and the spleen lack palpability.
Neuro: The patient is oriented everywhere and alert. He does not disobey commands. All of his extremities move when instructed.
Skin: The skin is intact, pink, and dry. It does not have tenting.
EKG: The interpretation of the EKG shows regular sinus rhythm. There are no changes in the ST as well.
Diagnostics
The patient should undergo an X-ray examination of the chest (Ball et al., 2017). He should also have a fasting lab workup that includes liver function, BNP, CBC, Hgb A1C, electrolytes, cardiac enzymes, and lipid profile tests. These tests can be instrumental in confirming the exact illness troubling Mr. Foster.
ASSESSMENT: from the assessment, the patients may be suffering from Coronary artery condition with stable angin
The differential diagnoses include the following:
Aortic aneurysm
Congestive heart failur
The patient’s angina or chest pain could be resulting from plaque buildup in the arteries responsible for supplying blood to the heart (Shahjehan & Bhutta, 2020). Coronary artery disease is among the most common conditions and causes blood flow impairment hence the delivery of oxygen to the myocardium. The patient’s significant history of hyperlipidemia and hypertension, as well as the family medical history of heart attacks, makes the patient be at risk of coronary artery disease. The patient indicated that the chest pain is mid-sternum and tight and that when the pain comes, it occurs for a minimum of five minutes and a maximum of half an hour and can be triggered with some hard work. The patient also had a thrill and bruit on the right side and an S3 gallop which usually results from increase fluid (Colyar, 2015). These symptoms suggest heart failure, which limits physical activity to an extent. With the condition, the patient can feel comfortable while resting. However, heart failure symptoms occur upon engaging in ordinary physical activity (Dains et al., 2019).
Vital signs:
Temperature: 97.9 oral
Respiratory rate: 32, labored
Heart rate: 112, tachycardic
BP right arm: 148/88
Oxygen saturation: 90% on room air
Weight: 210 lbs, stable
Skin: Cool, diaphoretic
Thorax and lungs: Thorax symmetrical; diminished breath sounds right middle and lower lobes; no rales, rhonchi, or wheezes; breath sounds vesicular with no adventitious sounds left lung
Cardiovascular: Heart rate is irregular with good S1, S2; no S3 or S4; no murmur
Abdomen: Protuberant with normoactive bowel sounds auscultated x4 quadrants
Peripheral vascular: Right calf with 2+ edema, erythema; warmth and tenderness on palpation noted; left lower extremity without edema or erythema; 2+ dorsalis pedis pulses bilaterally
——————————————————————————————————————————-
Instructions: Your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to the Comprehensive SOAP Template/Exemplar on the attachments below.
Address all these in the SOAP Note:
1. A description of the health history you would need to collect from the patient in the case study 2.
2. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis.
3. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
REMINDER: Please make a SOAP NOTE for this case. Make your own patient’s data, applicable health history, review of systems, P.E., labs, etc. Incorporate the data from the case 2 in the SOAP note that you will do… This is not essay ok…. I need SOAP note (Nurse Practitioner/RN/MD makes SOAP note)… Be guided with the templates/exemplar… Don’t copy paste. Formulate your own… Don’t forget to cite the Five different possible conditions (Differential diagnosis) and have Reference lists too.
RESOURCES:
Readings
· Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
o Chapter 13, “Chest and Lungs” (pp. 260-293)
This chapter explains the physical exam process for the chest and lungs. The authors also include descriptions of common abnormalities in the chest and lungs.
o Chapter 14, “Heart” (pp. 294-331)
The authors of this chapter explain the structure and function of the heart. The text also describes the steps used to conduct an exam of the heart.
o Chapter 15, “Blood Vessels” (pp. 332-349)
This chapter describes how to properly conduct a physical examination of the blood vessels. The chapter also supplies descriptions of common heart disorders.
· Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
o Chapter 8, “Chest Pain” (pp. 81–96)
This chapter focuses on diagnosing the cause of chest pain and highlights the importance of first determining whether the patient is in a life-threatening condition. It includes questions that can help pinpoint the type and severity of pain and then describes how to perform a physical examination. Finally, the authors outline potential laboratory and diagnostic studies.
o Chapter 11, “Cough” (pp. 118-147)
A cough is a very common symptom in patients and usually indicates a minor health problem. This chapter focuses on how to determine the cause of the cough through asking questions and performing a physical exam.
o Chapter 14, “Dyspnea” (pp. 159–173)
The focus of this chapter is dyspnea, or shortness of breath. The chapter includes strategies for determining the cause of the problem through evaluation of the patient’s history, through physical examination, and through additional laboratory and diagnostic tests.
o Chapter 26, “Palpitations” (pp. 310-317)
This chapter describes the different causes of heart palpitations and details how the specific cause in a patient can be determined.
o Chapter 33, “Syncope” (pp. 390-397)
This chapter focuses on syncope, or loss of consciousness. The authors describe the difficulty of ascertaining the cause, because the patient is usually seen after the loss of consciousness has happened. The chapter includes information on potential causes and the symptoms of each.
· Sullivan , D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.
o Chapter 6, “Outpatient Charting and Communications” (pp. 119–141)
Note: Download these Adult Examination Checklists and Physical Exam Summaries to use during your practice cardiac and respiratory examination.
· Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Blood vessels. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Blood Vessels Physical Exam Summary was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
· Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for cardiovascular assessment. In Mosby’s guide to physical examination(7th ed.). St. Louis, MO: Elsevier Mosby.
This Adult Examination Checklist: Guide for Cardiovascular Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
· Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for chest and lung assessment. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Adult Examination Checklist: Guide for Chest and Lung Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
· Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Chest and lungs. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Chest and Lungs Physical Exam Summary was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
· Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Heart. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Heart Physical Exam Summary was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
· McCabe, C., & Wiggins, J. (2010a). Differential diagnosis of respiratory disease part 1. Practice Nurse,40(1), 35–41.
Retrieved from the Walden Library databases.
This article describes the warning signs of impending deterioration of the respiratory system. The authors also explain the features of common respiratory conditions.
· McCabe, C., & Wiggins, J. (2010b). Differential diagnosis of respiratory diseases part 2. Practice Nurse, 40(2), 33–41.
Retrieved from the Walden Library databases.
The authors of this article specify how to identify the major causes of acute breathlessness. Additionally, they explain how to interpret a variety of findings from respiratory investigations.
· SkillStat Learning, Inc. (2014). The 6 second ECG. Retrieved from http://www.skillstat.com/tools/ecg-simulator#/-home
This interactive website allows you to explore common cardiac rhythms. It also offers the Six Second ECG game so you can practice identifying rhythms.
· University of Virginia. (n.d.). Introduction to radiology: An online interactive tutorial. Retrieved fromhttp://www.med-ed.virginia.edu/courses/rad/index.html
This website provides an introduction to radiology and imaging. For this week, focus on cardiac radiography and chest radiology.
Media
· Laureate Education. (Producer). (2012). Advanced health assessment and diagnostic reasoning. Baltimore, MD: Author.
Note: You will use the case studies presented in the media, Advanced Health Assessment and Diagnostic Reasoning, to complete this week’s Discussion.
· Online media for Seidel’s Guide to Physical Examination
In addition to this week’s media, it is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 13, 14, and 15 that relate to the assessment of the heart, lungs, and peripheral vascular system. Refer to Week 4 for access instructions on https://evolve.elsevier.com/.
Optional Resources
· LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009). DeGowin’s diagnostic examination (9th ed.). New York, NY: McGraw Hill Medical.
o Chapter 8, “The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts” (Section 1, “Chest Wall, Pulmonary, and Cardiovascular Systems,” pp. 302–433)
Note: Section 2 of this chapter will be addressed in Week 10.
This section of Chapter 8 describes the anatomy of the chest wall, pulmonary, and cardiovascular systems. Section 1 also explains how to properly conduct examinations of these areas.
Don’t wait until the last minute
Fill in your requirements and let our experts deliver your work asap.
Start My Order
