Physical assessment
3

Peripheral vascular system

Thelma H. Walker

Rasmussen College

COURSE#: NUR2180 Physical Assessment

Professor Casey Kelly

December 1, 2020

Subjective

Mr. Ortiz, an 88-year-old Mexican American man woman

Admitted diagnosis: Peripheral arterial disease

Medications: Rosuvastatin and clopidogrel simvastatin

Allergies: NKDA

Substance use: cigarette use (1 pack day for the last 50 years )

Status: Mr. Ortiz lives in along care facility. When asking the Patient about the circulation in his legs, he states that it is not very good. The Patient states he is experiencing an increase in pain, particularly when he is walking and occasionally when he is trying to sleep at night.

Pain: 6 /10 bilateral legs & feet.

Associated symptoms: Sensation in legs/feet and recent falls.

Past medical history: myocardial infarction 15 years ago, hypertension, hypercholesteremia, chronic renal failure(CRF0, and peripheral arterial disease (PAD)

Objective Information

Upon examination: vital sign: oral temp 36.8 C, HR 90 BPM, RR 18 and BP 140/92 mm Hg,

Upon an inspection, Thin, shiny, taut skin. Hair growth absent in bilateral lower extremities. Toenails are hard and thickened. Rubor on bilateral lower legs noted when limbs are dependent. Bilateral feet pale when elevated;

Upon palpation: 1+ dorsalis Pedi and posterior tibial pulses bilaterally. Feet cool. Capillary refill 7 seconds on bilateral lower extremities. Unable to differentiate between sharp versus dull sensation on bilateral feet and lower legs (below knee)

Risk Factors

References