Angele Wright, Comprehensive Health Assessment

Chief Complaint Lightheaded episodes x 2 with diaphoresis. Status post operative 12

days angioplasty with 2 stents placed. No complications noted
during or post procedure.

Patient denied chest pain or shortness of breath. Patient also stated:

“I just don’t feel right.”
HPI/10 Characteristics The patient denies pain at this time, so the characteristics of location,
radiation, quantity, or quality do not apply at this time.

Associated manifestations: besides the lightheadedness with

diaphoresis episodes x 2, the patient did not experience any other
signs or symptoms

Aggravating factors: “nothing made the feeling worse. I was

running a couple of errands with my wife and had this weird feeling
with a cold sweat come over me.”

Alleviated factors: N/A; it resolved on its own w/o direct

intervention by patient prior to arrival in the Emergency Department
(ED)

Setting: Each episode occurred in the grocery store, following

church service (approximately 1600). Status post operative 12 days
angioplasty with 2 stents placed. After the second episode occurred,
the patient decided to come to the ED for further evaluation. The
patient was concerned that something was wrong with his heart.

Timing: The episodes occurred after 1600 on Sunday, June 25th.

Each episode lasted under five minutes, was 15-20 minutes apart,
and occurred during normal activity. Resolved as suddenly as it
started and without intervention on the part of the patient.

Meaning/Impact: The lightheadedness was worrisome because

three years prior, the patient had similar symptoms and then learned
that he had a cardiac artery blockage that required his first
angioplasty and stent placement.
Past Medical/surgical hx Medical Hx
 Hypertension
 Hypercholesterolemia
 Coronary artery disease
Patient denies significant childhood illnesses, past illnesses or
injuries, previous blood transfusions, or special needs at this time
 Surgical Hx
 Percutaneous coronary intervention with radial access,
angioplasty with coronary artery stenting x 2 (June 13, 2017)
with no residual pain or complications
Allergies No known allergies to food, environment, or medicine

Current Rx  Plavix x 75 mg daily – antiplatelet therapy, taking 12 days

(previously took the plavix following the 1st PCI, but was taken
off after a year)
 Aspirin x 81 mg – antiplatelet therapy, taking three years
following the 1st PCI and stent placement
 Metoprolol x 50 mg – beta blocker, to reduce heart rate & blood
pressure, taking three years
 Atorvastatin x 10 mg – statin to reduce cholesterol levels,
specifically low density lipoprotein
 Daily men’s vitamin – supplement, ongoing, “taking for years, I
can’t remember.”
 Tylenol as needed for pain relief. Typical dose is 650 mg.
Family Heath Hx Both parents are alive and in relatively good health.
 Father:
o late 70s,
o hx of hypertension and high cholesterol,
o Experienced a mild heart attack “a few years back,” with
no residual deficits.
o Lives independently in family home with wife.
 Mother:
o mid 70s,
o hx of anemia and hypertension,
o had gallbladder removed,
o not sure if she takes blood pressure medication,
o but is in good shape and walks the mall every morning
 Patient has three biologically children: 18, 21, 22. Children are
in good health, no hx of childhood illnesses, children do not take
daily medication
 One brother: hx of hypertension, takes medicine. Unsure of
anything else
 Besides hypertension and heart disease, patient is unsure if
anything else runs in his family. Denies knowledge of diabetes,
cancer, or genetic diseases
Social Hx 1. ETOH: patient drinks the occasional beer or two at social
gatherings or crab feasts. Patient states that he probably has more in
the summer than any other time. Limits alcohol intake after first
stent placed three years ago.
 CAGE assessment:
o do you feel like you have to cut down on your drinking:
 “No.”
o do you feel annoyed by people complaining about your
drinking? “They don’t complain because I don’t drink
that much, so no.”
o do you ever feel guilty about your drinking? “No.”
o do you ever drink an eye-opener in the morning to relieve
shakes? “oh God, no.”

2. Smoking: patient denies the use of any tobacco product in the

past or present

3. Drug use: patient denies the use of any recreational or illicit

drugs in the past or present

4. Domestic violence screening: patient denies the presence of

violence in his home or in his relationships

5. Sexual orientation/birth control/number of partners:

heterosexual, married to 2nd wife and is in a monogamous,
committed relationship so no other birth control is used.

6. Type of employment: accountant

7. Education level: Bachelors of science in accounting, CPA

8. Economic status: middle class, employed with appropriate and

adequate health insurance
Spiritual Assessment FICA Tool:
 Faith and belief: “I am a Christian and a religious person. My
wife and I attend a local non-denominational church. My wife
and family give my life meaning. I went through a bad divorce
and then I met my now wife and she is the love of my life.”
 Importance: “After the placement of my first stent, my faith
and commitment to God got stronger. Attending church on a
weekly basis strengthens my relationship with myself and with
my family. Maybe it also has to do with getting older but I am
able to put things in perspective and not sweat the small stuff,
you know?”
 Community: We have friends at church but my wife is in
charge of communicating with them. I don’t actively participate
in church functions unless I am accompanying my wife. It is
nice to have friends at church who care for you and help you if
necessary. My wife has organized things in the past for our
friends, so I know if we needed help, they would assist us as
well.
 Interventions to address spiritual needs: Patient stated that he
 was okay with a visiting minister praying with him but did not
have any special requests at this time. “I shouldn’t be here too
long. I am good; I don’t need anything at the moment. But
thank you for asking.”
Cultural Assessment EACAT assessment
1. Ethnic group affiliation and racial background
 Lifelong Maryland resident
 Parents were born and raised in Pennsylvania, came to MD
to seek better employment
 Grandparents were farmers from Pennsylvania.
 Racial background is mostly English, Irish, and Scottish. I
have never been to England, Ireland, or Scotland. I just
know that it’s my racial background
 “I’ve always lived in Maryland, I have been relatively
healthy my entire life with the exception of having the stents
placed three years ago and 2 weeks ago. Even then, I did not
have chest pain, just intermittent lightheadedness and cold
sweats. My family, specifically my wife, helped me recover
from the stent placement.”
2. Major beliefs and values
 “Present. I give everyone the benefit of the doubt until they
prove me wrong.”
 “The purpose of life is to overcome your fears and become
the best version of yourself in the time you have. It is a
continuous process.”
 “A person can help you achieve or hinder you from progress.
It’s about finding the right person to be by your side. My
family is the most important thing to me. I haven’t really
given it much thought. I should, my grandparents were
farmers.”
 “No, I just practice regular holidays; Thanksgiving,
Christmas, etc.”
 “Work hard, play hard. Education is very important. My
children were all encouraged to do well in school and attend
college. We did our best to expose them to different things
in order to capture their attention on the importance of higher
learning. One is in college, one just graduated high school
with plans to attend college and one just graduated college
this past May.”
3. Health Beliefs and Practices
 “Being healthy means that you are an active participant in
your life. You are free from pain and limitations that can
curtail your pursuits and interests.”
 “Good nutrition, plenty of rest, exercise, limit stress, seek
care when necessary.”
 “I work out regularly, see my doctors when I am supposed
 to, take daily vitamins and eat well.”
 “Illness is an imbalance that needs to be corrected. I know
that I have a genetic predisposition to having hypertension. I
tried to work out and eat well but my blood pressure still
needed medication to manage it. I wasn’t always this careful
with my diet, which most likely affected my cholesterol
levels.”
 “When I don’t feel well, I go to the doctor or in this case, the
ED. I have confidence in their ability to care for me.
 “I typically am in good health. The time between the stents
placed, I worked out and only experienced minor colds. I
was able to take care of myself. I am pretty independent but
I like my wife’s company.”
 “I am well versed in caring for myself. I make my own
doctor’s appointments.”
 “I believe that all illnesses are chemical imbalances; both
mental and physical and should be treated as such. I believe
that it is still possible to live a full life even with a chronic
disease or handicapping condition. It is how you decide to
approach it. Pain is a part of life, as well as death and dying.
The key is to live your life while you have the time to do so.
Don’t worry about things that you cannot control. It will
drive you crazy.”
 No sanctions or restrictions observed at this time
 “Whoever is the best one available to treat me. I don’t care if
they are the same or different [cultural background, age, or
gender] as me. Let’s get this show on the road.”
4. Language barriers and communication styles
 English both written and spoken
 No issues understanding English
 Nothing specific – patient wants to be included in all
decisions and kept apprised of progress in moving to
inpatient room
 “Nothing out of the ordinary as far as I can see.”
 Denies any specific greetings or other forms of
communications needed
5. Role of the family, spousal relationship, and parenting styles
mother father Step
WIFE daughter
brother PATIENT
SIL

EX-WIFE
KID 1 KID 2

SON SON DAUGHTER

 “My family is basically 3rd or 4th generation English, Irish,

 Scottish. We pretty much follow American customs and
holidays. My wife, or ex-wife if it involves our kids; make
the decisions for my family, my brother and his wife for his
family and my parents determine their decisions by
themselves. We are pretty independent in our decision
making but we are available to help as needed.”
 “My parents, brother and his family, and my ex-wife all live
in Maryland. We all get together for special occasions;
holidays, birthdays and other festivities. Our family is pretty
healthy; we try to maintain good health despite our family
history of heart disease.”
 The patient stated that on a daily basis, he eats with his wife
and step-daughter on her days with her mother. In the past,
he shared custody of his children with his ex-wife and would
eat with them when they were physically in his household.
Now that his youngest is 18 years old, his biological children
are welcomed to enter his home as they wish without a pre-
set visitation schedule. He and his household walk and run
errands together and spend as much time together as
possible. The patient is satisfied with his interactional
patterns.
 “My wife and I celebrate major holidays and celebratory
events (births, marriages, holidays, etc.) together. We try to
celebrate it with my parents as they are getting older in a
pretty typical American way. We are a pretty low-key
family.”
 The patient stated that his family’s health and well-being are
pretty standard: they eat pretty healthily and work out. He
stated that he doesn’t have much control over his parents and
children’s practices but they are also active and pretty
healthy, despite the familial history of heart disease and
hypertension. His goal is to restore his good health and
prevent the need for another stent. The barrier to the goal is
the need for another stent.
 The patient stated that he and his family practice Western
medicine. He has faith in his health team (cardiologist,
primary care doctor and office staff). He stated that by
continuing with frequent follow up visits, they were able to
visualize the need for a new stent 12 days prior without the
presence of chest pain or discomfort.
 Socially, patient stated that he spends most of his time with
his wife. They socialize as a couple with personal friends,
church functions, and work activities. During the assessment
and time spent in the ED, the patient’s wife left to take
daughter to get food and then home with the intent to return
to be with the patient. Patient was comfortable remaining in
 the ED by himself and awaiting her return.
 The patient stated that they celebrate marriages, christenings,
funerals and death appropriately. Patient was extremely stoic
and straightforward during the assessment. Patient stated
that despite being in a bad marriage, he was able to work out
childcare details with his ex-wife and now, they are in a good
place socially. Patient was not extremely affectionate toward
his wife but it was obvious that they care for each other very
much.
 Patient’s father experienced a mild heart attack following a
history of heart disease and hypertension. Mother has
anemia, hypertension, and had a cholecystectomy. Both are
active, retired individuals with a full social life. Patient and
wife work full time, participate at least superficially in
church activities and work out. Patient is unsure of brother’s
family’s day to day activities but they seem to be in good
health. Patient’s children are good health and do not require
daily medication. They have their own social lives and
interact with their father appropriately.
6. Religious influences were discussed during the Spiritual
assessment section above

7. Dietary practices will be discussed in the Nutritional Assessment

below
Nutritional Assessment Part 1: General Diet Information
 Do you follow a particular diet? Yes, low fat, low cholesterol
diet with lean meats and vegetables.
 Favorite foods? I like sandwiches. My wife is going to bring me
one in a couple of minutes. Dislikes? I don’t really dislike
anything
 Strong cravings? Sandwiches!
 How often do you eat fast food? I don’t anymore.
 How often do you eat at restaurants? Once or twice a week
when I am out with my wife. Otherwise, we eat at home.
 Do you have adequate financial resources to purchase your food?
Yes
 How do you obtain, store, and prepare your food?
Supermarkets, keep it in the refrigerator at home, and prepare in
our kitchen
 Do you eat alone or with a family member or other person? I
usually eat with my wife but if she is out, I can eat alone.
 Do you consume any food supplements (e.g. high caloric
beverages) No
 In the past 12 months, have you:
o Experienced any change in weight? No
o Had a change in appetite? No
 o Had a change in your diet? No
o Experienced nausea, vomiting, or diarrhea in your diet?
No
o Changed your diet because of difficulty in feeding
yourself, eating, chewing, or swallowing? No
Part 2: Food Intake History (24-hour recall)
 6/24 12:00 salad with grilled chicken & water eaten at home
with wife
 6/24 14:00 fruit salad & jello
 6/24 19:00 vegetable noodles with ground turkey and tomato
sauce with water. Prepared by wife, eaten at home.
 6/25 08:00 egg whites, turkey bacon prepared at home, eaten
with wife. Cup of coffee.
 6/25 18:00 grilled chicken sandwich with spinach and tomatoes
from local restaurant with ginger ale, eaten in hospital
Health Maintenance  Sleep: 6-7 hr/night. Patient stated that he tries to get proper
sleep each nigh
 Exercise: walking on trail near home since procedure; prior to
PCI, patient stated that he exercised 3-4 times/week in the gym,
focusing on cardio and weight training
 Stress management: patient stated that his increased
participation in church has helped with his stress. It has allowed
him to put certain things into perspective and not worry about
things that he has no control over.
Review of systems  General: Patient appears to be in good condition, was able to
walk to room on his own accord. Patient’s energy levels were
appropriate, no body odors present, no fevers, chills, or night
sweats
 Skin: diaphoresis occurred prior to arrival. Resolved without
direct intervention. Otherwise, patient’s skin was appropriate
 Hair: no alopecia or excessive hair growth. No dandruff,
pediculosis, or scalp lesions visualized
 Nails: no changes in nails. No splitting, breaking, thickening,
texture change, onychomycosis, or use of chemicals
 Eyes: No blurred vision or changes in visual acuity, use of
glasses or corrective lenses. No drainage, blind spots, floaters,
cataracts, eye injury, use of protective eyewear
 Ears: patient experience lightheadedness prior to arrival.
Resolved prior to arrival. Other than that, no hearing deficits or
tinnitus. Patient does not use a hearing aid. Patient denies
phonophobia, discharge, unusual noise level, earaches, infection,
piercings, use of ear protection, or abnormal amount of cerumen
 Nose and sinuses: patient does not experience seasonal allergies,
epistaxis, postnasal drip, stuffiness, sinusitis, nasal polyps,
obstruction, change in sense of smell
 Mouth: patient brushes at least once per day. Patient has good
dental health. Denies presence of tooth abscess, dentures,
bleeding or swollen gums, difficulty chewing, sore tongue,
change in taste, lesions, change in salivation, bad breath, caries,
teeth extractions, orthodontics
 Throat and neck: no changes in voice or hoarseness. Patient
denies frequent sore throats, dysphagia, pain or stiffness, goiters,
lymphadenopathy, tonsillectomy, adenoidectomy
 Breasts and axilla: no changes in breast tissue. Denies pain,
tenderness, dimpling, rash, benign breast disease,
 Respiratory: denies dyspnea on exertion, shortness of breath,
sputum, cough, sneezing, wheezing, hemoptysis, frequent upper
respiratory tract infections, pneumonia, emphysema, asthma,
bronchitis, pulmonary emboli, tuberculosis or exposure to
tuberculosis, last chest x-ray (taken 6/25) was normal
 Cardiac: presence of coronary artery disease. Denies
paroxysmal nocturnal dyspnea, chest pain, heart murmur,
congestive heart failure, palpitations, syncope, orthopnea,
myocardial infarction, dysrhythmia, valvular disease, last EKG
was normal
 Peripheral vasculature: presence of hypertension. Denies
cyanosis, edema, cold or discolored hands or feet, leg cramps,
peripheral vascular disease, intermittent claudification, varicose
veins, thrombophlebitis, deep vein thrombosis, use of support
hose
 Gastrointestinal: No recent changes in appetite, vomiting,
diarrhea, constipation, usual bowel habits, change in bowel
habits, melena, rectal bleeding, hematemesis, change in stool
color, flatulence, belching, regurgitation, heartburn, dysphagia,
abdominal pain, jaundice, ascites, hemorrhoids, hepatitis,
Helicobacter pylori infection, peptic ulcers, gallstones,
gastroesophageal reflux disease, appendicitis, ulcerative colitis,
Crohn’s disease, diverticulosis/diverticulitis, umbilical ventral
hernia, last colonoscopy was normal
 Urinary: patient denies changes in urine color, voiding habits,
dysuria, hesitancy, frequency, nocturia, polyuria, dribbling, loss
in force of stream, bedwetting, change in urine volume,
incontinence, urinary retention, suprapubic pain, flank pain,
kidney stones, urinary tract infections
 Musculoskeletal: patient denies joint stiffness, muscle pain,
cramps, back pain, limitation of movement, redness, swelling,
weakness, bony deformity, broken bones, dislocations, sprains,
crepitus, gout, arthritis, osteoporosis, herniated disc, spasm
 Neurological: denies headache, change in balance,
incoordination, loss of movement, change in sensory perception
or feeling in an extremity, paresthesia, change in speech, change
 in smell, syncope, loss of memory, tremors, involuntary
movement, loss of consciousness, seizures, weakness, head
injury, vertigo, tremor, tic, paralysis, stroke, spasm
 Psychological: patient showed no evidence of irritability,
nervousness, tension, increased stress, difficulty concentrating,
mood changes, suicidal thoughts, suicide attempts, depression,
anxiety, sleep disturbances, eating disorders
 Male reproductive: patient denies changes in libido, infertility,
sterility, impotence, pain during intercourse, age at onset of
puberty, testicular or penile pain, penile discharge, erections,
emissions, hernias, enlarged prostate, type of birth control,
performs monthly testicular examinations
 Nutrition: patient is at his desired weight. Denies food
intolerances, follows a healthy diet, does not have any distinct
food dislikes.
 Endocrine: Diaphoresis x 2 episodes lasting under 3-5
minutes. Patient does not exhibit exophthalmos, excessive
fatigue, change in size of head, hands, or feet. No recent weight
change, appropriate heat and cold tolerance. Denies polydipsia,
polyphagia, polyuria, increased hunger, change in body hair
distribution, goiter, diabetes mellitus
 Lymph nodes: denies enlargement or tenderness of lymph nodes
 Hematological: denies easy bruising or bleeding, anemia, sickle
cell anemia, blood type, blood product infusions, or exposure to
radiation
Physical Exam General Survey
 Actual Age (53 years old) seems congruent with apparent age
 Patient is well-groomed, pleasant body and breath odor, walked
without assistance or distress.
 No evidence of body asymmetry, obvious deformities, or
distinctive markings
 Body fat is evenly distributed; with the exception of a rounded
abdomen, patient appears to be within normal limits on height
and weight
 Stature is proportional to body height with an erect posture
 Gait is smooth and confident with purposeful movement
 Patient is alert and oriented x 4, in a pleasant mood and
demonstrates a cooperative manner
 Patient responds to questions with ease. No evidence of slurred
speech or abnormal speech cadence
 Patient does not appear to be in any distress at this time. No
signs of labored breathing, wheezing or coughing. Patient’s
facial expression is calm and open.

Vital Signs
 Respiration rate: 18 breaths per minute. Patient’s respiratory
rate is within normal limits
 Pulse: rate is 68 beats per minute, rhythm is regular with a
normal volume. This RN palpated the radial pulse to assess rate,
rhythm, and volum.
 Temperature: 37.1 C oral. Patient is afebrile and denies recent
history of fevers or illnesses.
 Blood pressure: 127/68 using an automatic sphygmomanometer.
Patient stated that he took his hypertension medication this
morning but is slightly nervous that something could be wrong.
 Pain: 0/10. Patient denies any presence of pain anywhere in his
body.

Skin, Hair, and Nails (patient changed into a hospital gown)

 Patient’s skin was intact with no variety in color, temperature,
vascularity, texture, and turgor.
 There was no evidence of abscesses, masses, ecchymosis,
petechiae, purpura, spider angiomas, edema, lesions, moisture, or
bleeding.
 Patient had no distinctive tattoos, scars, or markings.
 Mucous membranes were moist, pink, and intact.
 No abnormal hair growth or loss
 Fingernails have normal shape, configuration, texture, and color.
 Normal capillary refill within 2 seconds.

Head, Neck, and Regional Lymph Nodes

 Head is normocephalic and symmetrical
 Patient’s head is smooth and nontender. No indentations or
masses present. Temporal artery is nontender
 Scalp is intact, absent of lesions or masses and appears to be
clean
 Face and features are symmetrical and proportional. Face is
absent of edema and lacks involuntary movement.
 Patient denies history of Bells Palsy or neurological tics.
 Jaw is smooth and patient does not experience discomfort when
talking or eating. No snapping or clicking sounds are evident
when mouth is opened
 Neck muscles are symmetrical. Head is able to move
appropriately without distress or discomfort. Patient is able to
breathe freely through his nose and mouth
 Patient’s thyroid tissue moves appropriately during swallow
screen. Patient’s Adam’s apple is appropriately prominent
 No enlargement, masses, or tenderness were found during
palpation. No bruits were auscultated.
 Lymph nodes were not visible, palpable or tender to touch.
Eyes
 Patient’s eyes were symmetrical. Patient does not display any
visual deficiencies
 External eye does not demonstrate drooping, drainage,
ecchymosis, masses, or lesions.
 Eyelids are appropriate for ethnic background
 Lacrimal apparatus is not enlarged, swollen, or red. Appropriate
tearing or moisture but no exudates present when inspected and
palpated
 Extraocular muscle function/cardinal fields of gaze are within
normal limits
 Corneal light reflex present in both pupils
 The bulbar conjunctiva and palpebral conjunctiva are within
normal limits
 The sclera is white with minimal superficial vessels. No
evidence of exudates, lesions or foreign bodies
 Cornea is moist and shiny, with no discharge, cloudiness,
opacities, or irregularities
 No evidence of glaucoma, entire iris is illuminated
 The pupils were equal, round, reactive to light and
accommodation
 No ophthalmoscope available to check posterior segment
structures

Ears, Nose, Mouth, and Throat

Ears
 Patient was able to repeat whispered words: mama, tiptop, fifty-
fifty w/o difficulty or discomfort
 This RN was unable to conduct the Weber and Rinne tests
because no tuning forks were available
 External ear exhibited the same color as the remainder of the
patient’s skin.
 Ear is positioned centrally and in proportioned to the patient’s
head and lines up with the outer cantus of the eye.
 Patient denies tenderness or pain when auricle is palpated.
 Ear canal reflects no redness, swelling, tenderness during
visualization. No foreign bodies, scaly surface areas, drainage
visualized
 Tympanic membrane is pearly gray with no obvious bulging or
fluid present behind it.

Nose
 Nose is present in the midline of the face. No evidence of
swelling, bleeding, lesions, or masses. Both nostrils are patent
 Nasal mucosa is pink without swelling or polyps; septum is
 mildy deviated but is not perforated. Patient denies nasal
trauma. No bleeding present. No purulent discharge present
 No swelling present around nose and eyes. Patient denies
discomfort when sinuses are palpated

Mouth
 Patient’s breath is pleasant. No signs of inflammation is present
in lips or tongue
 Mucus membranes are pink and moist; no evidence of
inflammation or lesions are present
 Lips are not flaccid
 Tongue is midline, moist, and absent of lesions
 Buccal mucosa is pink, moist, and smooth. No evidence of
lesions or inflammation
 Gums are pink, smooth, absent of masses, bleeding, or swelling.
No dental caries or fractured teeth present. No missing teeth
present. Teeth are in alignment
 Patient’s hard and soft palate are concave and pink and within
normal limits. No evidence of lesions or malformations present

Throat
 Uvula is midline. Throat is pink and without swelling, lesions,
or inflammation. Tonsillar size is 1+. Patient is able to protect
his airway with an intact gag reflex. Uvula and soft palate rises
appropriately when patient says “ah.”

Thorax and Lungs inspection

 Ratio of AP diameter to the transverse diameter is appromixately
1:2. No evidence of barrel chest present
 Patient’s shoulders and scapula are the same height bilaterally.
No masses present
 No dilated superficial veins are present and
 the patient’s costal angle is > 90 degrees and ribs are within
normal limits.
 During normal inspiration and expiration, there is no evidence of
bulging of intercostal space
 No accessory muscles are used in normal breathing
 Respiratory rate is 18 breaths per minute or eupnea, respirations
are regular and even, nonexaggerated, and chest falls and rises
appropriately
 No masses, pulsations, tenderness present during palpation
 No crepitus present during palpation
 Thoracic expansion and tactile fremitus are within normal limits
 Trachea is midline in the suprasternal notch
 During percussion, a resonant sound was produced over lung
 tissue. Over the heart, a dull sound was produced.
 Breath sounds are clear, absent of crackles, stridor, or wheezing.

Heart
 During inspection, no pulsations are visible in the aortic,
pulmonic, midprecordial, tricuspid, and mitral areas. Patient’s
musculature prevents visible pulsation of mitral area.
 .No pulsations, thrills or heaves are palpated in the aortic,
pulmonic, midprecordial, tricuspid, and mitral areas. Patient’s
musculature prevents palpation of pulsations, thrills, or heaves in
his mitral area.
 S1 and S2 sounds are regular. No additional heart sounds, such
as murmurs, rubs, or clicks, are present.

Peripheral Vasculature & Lymphatic System

 Patient asked to lay in low fowler’s position. No jugular venous
distension present at 45 degree angle
 No change in jugular veins when pressure is placed on right
upper quadrant.
 Mild JVD present when patient is placed in supine position.
Quickly disappears when patient sits upright.
 Regular, symmetrical peripheral radial and pedal pulses are
present
 No discoloration or ulcerations present on bilateral upper and
lower extremities
 Epitrochlear and iguinal lymph nodes are not visible, palpable,
or tender. No redness present

Abdomen
 Patient’s abdomen is rounded, symmetrical, absent of scars or
distinctive markings. Color and pigmentation is uniform
throughout.
 No retractions, masses, or nodules are evident during inspection.
 Peristalsis and pulsations are not evident during inspection.
 Umbilicus is below the abdominal surface
 High pitched bowel sounds are present in all four quadrants.
 No evidence of bruit, rubs, or hums are present during
auscultation
 Normal percussion sounds were heard. Over epigastric area and
LLQ, a tympanic sound was heard. Over RUQ, LUQ, and RLQ,
a dull sound was heard.
 The liver span was 10 cm. Appropriate for a man
 Liver descent was 2 cm. Appropriate for a man
 Patient denies bilateral CVA tenderness during fist percussion
 No guarding, abnormal tenderness, masses, bulges, or swelling
 present during abdominal palpation

Musculoskeletal System
 Patient is 70” and 98 kg
 No obvious deformities or indications of discomfort during
inspection
 Posture is erect and upright with no obvious kyphosis
 Gait is smooth, rhythmic, and confident. No limps observed.
Arms swing appropriately through and coordinated with the
opposite leg
 Joint contours are smooth and rounded in flexion and flat in
extension. No swelling, edema, ecchymosis, deformities,
masses, or distinctive skin markings present.
 Muscle tone is appropriate and all extremities demonstrate
appropriate range of motion against gravity and applied
resistance
 All joints (TMJ, shoulders, elbows, wrists, phalanges, hips,
knees, ankles, and toes) are symmetrical and equal in their range
of motion. No unilateral weakness detected during assessment.
 Normal calluses were detected on palms of hands and feet during
assessment

Neurological System
 Patient is alert and oriented x 4 (person, time, place, and
situation).
 GCS is 15
 Patient is able to answer questions quickly and clearly without
evidence of global aphasia.
 Patient is able to repeat words without difficulty. Thoughts
appear to be logical and coherent. No difficulty explaining
abstract concepts or calculating simple sums.
 Patient has no issue drawing items as directed.
 Patient denies SI.
 Patient is able detect light and deep touch and temperature
changes and correctly identify changes of position of body parts
without difficulty
 Extinction is intact.
 All 12 cranial nerves, coordination, and pronator drift are within
normal limits.
 Superficial, deep, and pathological reflexes are intact

Nursing Diagnoses 1. Risk for decreased cardiac output related to vasoconstriction as

evidenced by need for recent cardiac artery stenting,
lightheadedness, and diaphoresis
 Patient goal: patient’s cardiac output will remain within
 appropriate levels by the use of antiplatelet therapy,
appropriate lifestyle choices, and statin drug use.
 Intervention: patient will follow up with primary care
provider to ensure that his LDL numbers are decreasing
appropriately. If not, he and provider will adjust his
medications appropriately.

2. Ineffective cardiac tissue perfusion related to impaired coronary

artery circulation as evidenced by lightheadedness and diaphoresis.
 Goal: provider will be able to identify if lightheadedness and
diaphoresis are related to cardiac dysrhythmias or caused by
something else.
 Intervention: monitor cardiac rhythm to ensure that rate,
regularity, and rhythm are within normal limits.