You will perform a history of a cardiac problem that your instructor has provided you or one that you have experienced, and you will perform a cardiac assessment. You will document your subjective and objective findings, identify actual or potential risks, and submit this in a Word document to the drop box provided. please give references and plagiarism free
Introduction
Cardiovascular disease (CVD) refers to a group of disorders that affect the heart and blood vessels. It is a major cause of mortality and morbidity worldwide, with millions of people suffering from cardiac problems each year (World Health Organization, 2017). In this assignment, we will perform a history and cardiac assessment on a patient with a known cardiac problem to assess their current health status and identify any potential risks.
Patient History
The patient, Mr. Smith, is a 60-year-old male with a history of coronary artery disease (CAD). CAD occurs when there is a buildup of plaque in the arteries that supply oxygen-rich blood to the heart (Mayo Clinic, 2019). Mr. Smith was diagnosed with CAD two years ago, and since then he has been on medication and has made lifestyle modifications to manage his condition. He is a non-smoker and has reduced his intake of saturated fats and cholesterol.
Subjective Findings
During the history-taking process, Mr. Smith reports occasional episodes of chest pain, known as angina. He describes the pain as a pressure or tightness in the chest that occurs during physical exertion and subsides with rest. He rates the severity of the pain as 6 out of 10 on a visual analog scale. The pain typically lasts for a few minutes and is relieved by taking nitroglycerin sublingually, as prescribed by his cardiologist.
Mr. Smith also reports experiencing shortness of breath during physical activities such as climbing stairs or walking uphill. He denies any palpitations, dizziness, or syncope. He expresses concern about his condition and mentions that he has been feeling more fatigued recently.
Objective Findings
On physical examination, Mr. Smith’s vital signs are within normal limits. His blood pressure is 128/82 mmHg, heart rate is 76 beats per minute, respiratory rate is 16 breaths per minute, and oxygen saturation is 98% on room air. His height is 6 feet, and he weighs 180 pounds, giving him a body mass index (BMI) of 24.4 kg/m², which falls within the normal range. His waist circumference is 38 inches.
Cardiac Auscultation reveals normal S1 and S2 heart sounds with no murmurs or extra heart sounds. Pulses are palpable and equal bilaterally, and capillary refill is less than two seconds in all extremities. There are no signs of peripheral edema.
Mr. Smith’s ECG shows normal sinus rhythm with no significant ST-segment changes or Q waves. Blood tests reveal normal lipid profile (total cholesterol: 185 mg/dL, LDL cholesterol: 110 mg/dL) and a fasting blood glucose level of 95 mg/dL.
Actual and Potential Risks
Based on Mr. Smith’s history and objective findings, there are several actual and potential risks that should be addressed. The main actual risk is the presence of angina, which indicates ongoing ischemia and inadequate blood flow to the heart. This can lead to myocardial infarction if left untreated. The potential risk factors include shortness of breath and fatigue, which may indicate worsening cardiac function or the development of heart failure. Monitoring these symptoms is crucial to prevent further complications. Additionally, Mr. Smith’s weight and waist circumference are within normal ranges, but it is important to maintain a healthy weight to reduce the risk of further cardiovascular events.
Conclusion
In conclusion, Mr. Smith, a 60-year-old male with a history of CAD, presents with angina, shortness of breath, and fatigue. Objective findings indicate normal vital signs, normal cardiac auscultation, and no peripheral edema. The ECG shows normal sinus rhythm, and blood tests reveal a normal lipid profile and fasting blood glucose level. Based on the subjective and objective findings, the actual risks include ongoing ischemia and potential risks include worsening cardiac function or the development of heart failure. Regular monitoring and management of these risks are essential to prevent further complications and improve Mr. Smith’s quality of life.