Peripheral Vascular System Patient Case

Peripheral Vascular System Patient Case

Subjective

The patient’s name is Gonzalez. He is an eighty-year-old Mexican American who presents with a complaint of leg pain, which occurs when he is walking and is alleviated by rest. This pain makes it difficult for him to walk well. He states that the pain sometimes radiates to the left side of his foot. He says that the pain worsens at night and lasts for about two minutes. He rates the pain at a severity of 6/10. The patient states that he smokes ten cigarettes a day and drinks about three bottles of beer a day. He says that if the pain is so severe, he takes acetaminophen, which helps in reducing the severity. Massaging the calves and toes also helps in reducing the severity of the pain. The patient states that he thinks he has enlarged blood vessels in his legs. He says that his right leg is more painful than his left leg. He also says that he feels hot when he touches his right leg. These symptoms started two years ago, but they have been worsening in recent times. The patient is currently on Rosuvastatin for his hyperlipidemia and clopidogrel for peripheral arterial disease; additionally, his past medical history includes myocardial infarction fifteen years ago, hypertension, hyperlipidemia, and peripheral arterial disease. He has no known drug allergies and lives in a long-term care facility. Our assignment writing help is at affordable prices to students of all academic levels and academic disciplines.

Objective

Vital signs: Oral Temp 36.8 C, HR 90 BPM, RR 18, and BP 140/92 mm.

The inspection of the upper extremities shows normal appearances with no deformities or changes in vascularity. The lower limbs examinations reveal thin, shiny skin without hair. Palpation reveals cool feet with a capillary refill of seven seconds in the bilateral lower limbs. The sharp and dull sensations cannot be differentiated on the bilateral feet and below the knee. His upper limbs’ size and shape are symmetrical. The skin in his upper limbs is appropriate for his age. The capillary refill is <3s on the upper extremities. His radial pulses are steady, and the inguinal nodes are palpable. The left leg has hair growth, which is appropriate for his age. The right lower leg is thin and hot at the touch, with no hair growth. The peripheral pulses in the lower right leg are diminished. The left upper and lower extremities have an equal temperature, and the calf and the right foot are tender on palpation. Microfilament is felt on the left foot with intact sensations. Microfilament cannot be judged on the right lower foot.

Risk Factors

Mr Gonzalez is at risk of developing claudication. This is the pain that results from limited blood flow to muscles (). This pain occurs when an individual is walking for a certain period. This pain is not constant. It is usually present during exercise and relieved by rest (Mizzi et al., 2019). As the claudication worsens, the pain may be present during rest. Claudication is normally a symptom of a disease, especially peripheral artery disease, in which there is a narrowing of arteries in the extremities, leading to restricted blood flow (Mizzi et al., 2019).

The patient is also at risk of developing deep venous thrombosis. The risk factors that the patient has for DVT are age and smoking (Stone et al., 2017). The calf is tender on palpation, which may be the presence of a clot. DVT occurs due to the formation of a thrombus in deep veins, especially in the legs. It results in leg pain, swelling, discolored leg, and warmth (Stone et al., 2017).

References

Mizzi, A., Cassar, K., Bowen, C., & Formosa, C. (2019). The progression rate of peripheral arterial disease in patients with intermittent claudication: A systematic review. Journal of Foot and Ankle Research, 12(1). https://doi.org/10.1186/s13047-019-0351-0

Stone, J., Hangge, P., Albadawi, H., Wallace, A., Shamoun, F., Knuttien, M. G., Naidu, S., & Oklu, R. (2017). Deep vein thrombosis: Pathogenesis, diagnosis, and medical management. Cardiovascular Diagnosis and Therapy, 7(S3), S276-S284. https://doi.org/10.21037/cdt.2017.09.01

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Perform a history of a peripheral vascular problem. You will document your subjective and objective findings and identify actual or potential risks.

Peripheral Vascular System Patient Case

Documentation of problem-based assessment of the peripheral vascular system.

Purpose of Assignment:

I am learning the required components of documenting a problem-based subjective and objective assessment of the peripheral vascular system. Identify abnormal findings.

 Course Competency:

Select appropriate physical examination skills for the cardiovascular and peripheral vascular systems.

 Instructions:

 Content:  Use of three sections:

• Subjective
• Objective
• Actual or potential risk factors for the client based on the assessment findings with no description or reason for selection of them.