Peripheral Vascular System Patient Case

Patient Case- you should embellish and add additional details to the patient case as needed to reflect full documentation of a musculoskeletal problem, but please use the following basic information to document about your patient:

Subjective Data/history

Mr. Gonzalez, an 80-year-old Mexican American man

Current living situation: long-term care facility

Allergies: NKA

Past Medical History (PHM): Myocardial infarction 15 years ago, high blood pressure, high cholesterol, and peripheral arterial disease (PAD).

Medications: rosuvastatin for his cholesterol and clopidogrel for the PAD.

History of Present Illness (HPI): Mr. Gonzalez states that he is newly having leg pain when walking, but the pain is relieved with rest. Ask any other OLDCARTS you might be interested to know about Mr. Gonzalez’s symptoms

Objective Data/ Physical Exam:

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

Inspection: Upper extremities appear normal so document as such. Lower extremities have thin, shiny skin. Hair growth absent in bilateral lower extremities. Bilateral feet pale when elevated. Document rest of inspection as “normal”

Palpation: 1+ dorsalis pedis and posterior tibial pulses bilaterally. Feet cool. Capillary refill 7 seconds on bilateral lower extremities. Unable to differentiate between sharp versus dull sensations on bilateral feet and lower legs (below knee). Upper extremities and rest of palpation document as normal or expected findings.