VASCULAR CASE STUDY: History of Present Problem:

VASCULAR CASE STUDY: History of Present Problem: Oliver Jones is a 70 year old man that came to the ED complaining of pain and burning in his left leg. He reports increased pain while working in his yard. The pain has been increasing over the last year to the point where is not able to work in the yard as much as he used to. He states he used to be able to push mow his entire yard but now can only make a lap before the pain is unbearable for him. He states, “I cannot seem to feel my legs as much as I used to” and that he notices, “My legs change color when I sit down for a while.” Mr. Jones states that the pain used to go away when he rested but now bothers him more and more. He also has noticed a new “black spot” on his left great toe that “came up recently.” Personal/Social History: Mr. Jones lives independently at home. He is a widow and has 2 daughters. One lives nearby and helps Mr. Jones when he needs it. Current Assessment: GENERAL APPEARANCE: Resting on stretcher, no acute distress RESP: Lung sounds clear bilaterally, no adventitious sounds noted. CARDIAC: Pink, warm, dry. Trace non-pitting edema noted to bilateral lower extremities. Heart sounds regular, S1/S2 noted. Radial pulses 2+. Left dosalis pedis and posterior tibial pulses absent to palpation, noted faint with Doppler. Right dosalis pedis and posterior tibial noted 1+ faint by palpation. NEURO: Alert and oriented x 3. Moves upper extremities without difficulty. Bilateral lower extremities noted with generalized weakness. GI: Abdomen noted soft and nontender. Bowel sounds active x 4 quadrants. GU: Reports benign prostate hypertrophy. SKIN: Lower extremities noted with pallor while resting on stretcher. Pt reports rubor while legs are in dependent position. Hair loss noted on left lower legs with thick nails noted to left foot. Left extremity noted cool to touch. 1 cm x 1 cm blackened area noted to left great toe. Slight odor noted. Small amount purulent serosanguineous drainage noted to site. What assessment data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance:

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