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Father died at age 62 years from acute myocardial infarction; also had long-standing history of hypertension.

01 / 10 / 2021 Nursing

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Father died at age 62 years from acute myocardial infarction; also had long-standing history of hypertension. 
Mother is living at age 79 years.  She had a stroke at age 62 years and has been diagnosed with type 2 diabetes for 25 years. 

Psychosocial profile:
Nutritional patterns: Reports he tries hard to follow the diet the dietician gave him when he was first diagnosed with diabetes. Says it is hard to “eat healthy” lately and admits to not adhering to the prescribed diet. Attributes his current high blood glucose levels to this situation.  States his wife “nags” him all the time about his diet. 

Recreation/hobbies: States he is too busy to have any hobbies. After work, he eats dinner and watches television.

Occupational health patterns: Works as a salesman for a pharmaceutical company which requires long hours and frequent out of town travel. 

Environmental health patterns: lives in a ranch style house in suburbs; has central heating and air conditioning. 

Roles/relationships:  Lives with his wife of 34 years. They have two sons in college who come home summers and holidays.  The client and his wife enjoy going to movies and out to dinner with friends.  They used to take long walks during nice weather but have not done so for the past year. 

Physical assessment: 
General appearance:  Well nourished, in no acute distress, slightly anxious. 
Vital signs: Temperature 99.2° F; pulse 98 beats per minute (BPM) regular; respirations 16/minute, unlabored; BP 150/96 mm Hg; weight 200 pounds; height 5 feet, 9 inches; body mass index (BMI) 29. 

Inspection: 
Head and neck: head erect, midline. No jugular vein distention. 
Upper extremities: Skin color uniform, capillary refill < 3 seconds; no edema or skin lesions. 
Abdomen: protuberant; no visible pulsations
Lower extremities: Right leg pale. Left leg has erythematous areas from the ankle to midthigh; primarily over the lower leg. Capillary refill > 4 seconds. Toenails thickened and yellow.  Skin thin and shiny. Patchy hair loss. No varicosities. No visible edema right leg. Left leg obviously edematous from foot to midthigh. 

Palpation: 
Head and neck: temporal and carotid arteries +2 bilaterally. No lymphadenopathy or thyromegaly. 
Upper extremities: Brachial and radial pulses easily palpable, +2 bilaterally. Skin smooth and warm bilaterally. 
Abdomen: soft; no organomegaly; no abdominal pulsatile masses. 
Lower extremities: Femoral and popliteal pulses easily palpable. +2 bilaterally. Dorsalis pedis and posterior tibial pulses absent. Right foot cool to touch; left foot warm. +3 pitting edema of left leg. Calf circumference: right leg 20 cm, left leg 24 cm. 

Auscultation: 
Head and neck: no carotid bruits
Upper extremities: BP 156/96 mm Hg right arm; 158/94 left arm. 
Lungs and thorax: Clear anterior and posterior 
Heart: S1S2 audible; regular rhythm at 98 beats per minute. No murmurs or rubs. 
Abdomen: Bowel sounds present X 4 quadrants; no vascular sounds auscultated.  


 Identify abnormal findings from the physical assessment and the significance of each. (Total 4 points) (example: body mass index = 29 – exceeds recommendation of 24-27 for older adult; increased health risk related to obesity) 



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