Discussion: Peripheral Vascular System Health Assessment
SUBJECTIVE DATA:
Chief Complaint (CC): “Chest pain”
History of Present Illness (HPI): A 58-year-old Caucasian male, identified as P.D., visits the clinic with a primary concern of sporadic and intense chest pain. Within the last month, he reports three different occurrences of this symptomatology, each with a short episode. The patient later recognized that the discomfort he experienced might be due to heartburn. The patient assigns a score of 0 out of 10 to his current state of despair, with a possible maximum score of 5. The patient reports experiencing localized tightness and pain in the central chest region without any radiation to other body areas. The patient claims pain is relieved when immobile or at rest but worsens when they engage in physical activities like raking leaves or climbing stairs. Furthermore, he reported chest discomfort following episodes of overeating.
Location- the center of the chest.
Quality- uncomfortable and tense
Quantity or severity- 5/10 at worst.
Timing, including onset, duration, and frequency- three times every month, for a little period each time.
Setting in which it occurs- when undertaking yard upkeep at home.
Factors that have aggravated or relieved the symptom: Walking up the stairs aggravates his chest discomfort, which is alleviated when he sleeps.
Associated manifestations- Mild leg cramps as a result of moving
Medications: Lipitor once daily at a dosage of 20 milligrams; Lisinopril 20 mg once every day; 1200 mg of Omega-3 Fish Oil orally twice a day. Ibuprofen 200 mg, as needed, every four hours for the pain.
Allergies: He feels sick after taking codeine. Denies sensitivity to particular foods or environments.
Past Medical History (PMH):
- The patient has hyperlipidemia and stage II hypertension.
Past Surgical History (PSH):
- He underwent a colonoscopy at the age of 50.
Sexual/Reproductive History: He has engaged in only one instance of sexual activity during his 27-year marriage.
Personal/Social History: The patient is a licensed professional engineer. He has been married to his wife for 27 years. The patient is a mother with a 19-year-old daughter and a 26-year-old son. He asserts having a family doctor even though he had not had an appointment with them for three months. The client refutes using illicit substances like marijuana, heroin, cocaine, or any combination. The individual consumes up to three beers during the weekends. He has ceased his regular bicycle riding. Upon obtaining approval from the physician, he intends to commence his exercise regimen. The patient engages in recreational fishing activities with his companion and sibling. The patient occasionally consumes fried food but maintains satisfactory health.
Immunization History:
- The Tdap vaccine was administered in October 2015.
- Current on all other immunizations.
- The patient denies to be vaccinated against pneumonia.
Significant Family History:
- Father had obesity hyperlipidemia and died from colon cancer at 71.
- His mother passed away at 62 and had a medical history of hypertension (HTN) and type 2 diabetes.
- His sister is 54 and diagnosed with type 2 diabetes mellitus (DM) and hypertension (HTN).
- His brother died in a car accident at 27 years old.
- The children are in good health.
- He claims not to know the familial background of their grandparents.
Review of Systems:
Constitutional: denies experiencing fatigue and attributes a weight gain of 15-20 pounds to a lack of physical activity over the past few years. He also reports the absence of night sweats, fever, or chills.
HEENT: denies any alterations in visual acuity, throat discomfort, or swallowing difficulties.
Skin: denies having pallor and cyanosis
Respiratory: denies experiencing discomfort during inspiration and dyspnea.
Neurological: denies experiencing symptoms such as faintness, dizziness, numbness, or tingling in their extremities.
Cardiovascular: has ongoing chest pains, is unable to exercise because it makes the discomfort worse, denies palpitations, denies having ever had cyanosis or blood clots, and reports easy bleeding or bruising.
Gastrointestinal: denies suffering nausea, diarrhea, or feeling bloated or constipated.
Musculoskeletal: denies having back, joint, or muscular discomfort. Balance and gait are unaltered.
Psychiatric: denies feeling anxious, sad, or going through emotional upheavals.
OBJECTIVE DATA:
Physical Exam:
Vital signs: The patient had 146/88mmHg blood pressure, 104 beats per minute pulse, 19 breaths per minute respiratory rate, 98% oxygen saturation on room air, 36.27°C body temperature, and 5/10 pain.
General Exam: The adult patient, who is alert and oriented, appears to be experiencing discomfort while lying in a supine position on a hospital bed. The individual displays mild diaphoresis, pallor, and an elevated respiratory rate.
Skin: The skin appears intact, warm, and dry, with slight sweating and paleness. No signs of pus, redness, or hardening are observed.
Respiratory: The patient’s breath sounds in the upper lobes of the lungs and right middle lobe are clear, with unlabored and quiet breathing. Fine crackles/rakes are present at the posterior bases of the lungs.
Neurological: The patient is alert and oriented in time, place, and person (AOX3), demonstrates full range of motion in all extremities, and exhibits compliance with commands.
Cardiovascular: S1 and S2 were auscultated without any audible rubs or murmurs. Brachial, radial, and femoral pulses exhibit no thrills at a 2+ intensity. The popliteal, dorsalis pedis and tibia pulse show no thrill at a 1+ intensity. In all four extremities, capillary refill takes less than three seconds. The jugular venous pressure (JVP) measures at 3cm. The left carotid pulse exhibits a 2+ bruit, while the right carotid pulse demonstrates a 3+ bruit. Lateral displacement of the point of maximal impulse (PMI) and the presence of an S3 is observed in the mitral area. There are no varicosities, induration, localized erythema, or edema in the lower extremities.
Gastrointestinal/ The abdomen appears round and soft without any distension. Bowel sounds are within normal range, with no abnormal sounds such as bruits. There is no enlargement of the liver or spleen (hepatosplenomegaly). The kidneys and spleen cannot be felt upon palpation.
Diagnostic Test/Labs: The EKG showed a normal sinus rhythm with no ST-segment elevation (Joshi & de Lemos, 2021).
ASSESSMENT:
- Coronary Artery Disease (CAD) with stable angina: The patient reported experiencing persistent chest pain that intensified during physical activity and subsided upon resting. He linked the pain to a ” pressure ” sensation on the left shoulder (Severino et al., 2019). The patient had CAD risk factors, including hyperlipidemia, male gender, physical inactivity, family history of heart diseases, hypertension, and a sedentary lifestyle (Maurovich-Horvat et al., 2022).
- Carotid Artery Disease: Coronary artery disease can lead to acute coronary syndrome and persistent ischemic heart disease (Bytyçi et al., 2021). Untreated cases may result in the development of congestive heart failure. When a person presents with chest discomfort, it is crucial to ascertain the location, intensity, and associated symptoms to determine its origin and potential impact on other bodily regions.
- Gastroesophageal reflux disease (GERD): Heartburn is a frequently observed and prevalent symptom of GERD. Heartburn is a condition marked by a burning feeling in the chest that may also be felt in the oral cavity and is brought on by acid reflux into the esophagus (Katzka & Kahrilas, 2020).
- Pericarditis: Pericarditis refers to the inflammatory condition of the pericardium, a delicate sac-like tissue enveloping the heart (Chiabrando et al., 2020). Chest pain is a common symptom of pericarditis. Chest pain arises from the friction between the layers of the inflamed pericardium.
References
Bytyçi, I., Shenouda, R., Wester, P., & Henein, M. Y. (2021). Carotid Atherosclerosis in Predicting Coronary Artery Disease. Arteriosclerosis, Thrombosis, and Vascular Biology, 41(4). https://doi.org/10.1161/atvbaha.120.315747
Chiabrando, J. G., Bonaventura, A., Vecchié, A., Wohlford, G. F., Mauro, A. G., Jordan, J. H., Grizzard, J. D., Montecucco, F., Berrocal, D. H., Brucato, A., Imazio, M., & Abbate, A. (2020). Management of Acute and Recurrent Pericarditis. Journal of the American College of Cardiology, 75(1), 76–92. https://doi.org/10.1016/j.jacc.2019.11.021
Joshi, P. H., & de Lemos, J. A. (2021). Diagnosis and Management of Stable Angina: A Review. JAMA, 325(17), 1765–1778. https://doi.org/10.1001/jama.2021.1527
Katzka, D. A., & Kahrilas, P. J. (2020). Advances in the diagnosis and management of gastroesophageal reflux disease. BMJ, 371. https://doi.org/10.1136/bmj.m3786
Maurovich-Horvat, P., Bosserdt, M., Kofoed, K. F., Rieckmann, N., Benedek, T., Donnelly, P., Rodriguez-Palomares, J., Erglis, A., Štěchovský, C., Šakalyte, G., Čemerlić Adić, N., Gutberlet, M., Dodd, J. D., Diez, I., Davis, G., Zimmermann, E., Kępka, C., Vidakovic, R., Francone, M., & Ilnicka-Suckiel, M. (2022). CT or Invasive Coronary Angiography in Stable Chest Pain. New England Journal of Medicine, 386(17), 1591–1602. https://doi.org/10.1056/nejmoa2200963
Severino, Mather, Pucci, D’Amato, Mariani, Infusino, Birtolo, Maestrini, Mancone, & Fedele. (2019). Advanced Heart Failure and End-Stage Heart Failure: Does a Difference Exist? Diagnostics, 9(4), 170. https://doi.org/10.3390/diagnostics9040170
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