module 08 written task – assess and doc | Well being Evaluation | Rasmussen School System
Subjective information: Through the interview, I’d ask the affected person about any signs they’re experiencing, akin to ache, cramping, numbness, or tingling of their legs or arms. I’d additionally inquire about their medical historical past, particularly if they’ve a historical past of diabetes, hypertension, or coronary heart illness. Moreover, I’d ask about their way of life, akin to smoking or bodily exercise stage, as these can have an effect on the vascular system.
Goal information: Through the bodily examination, I’d begin by observing the affected person’s legs or arms for any seen indicators of swelling or discoloration. I’d then palpate their peripheral pulses, such because the radial, brachial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses, assessing for any irregularities or diminished pulses. I’d additionally test for any indicators of varicose veins or edema. Lastly, I’d carry out the ankle-brachial index take a look at to evaluate for any blockages within the arteries of the decrease extremities.
Documentation of findings: Affected person experiences occasional numbness and tingling of their toes, significantly after extended standing or strolling. Affected person has a historical past of sort 2 diabetes and hypertension, and presently smokes half a pack of cigarettes per day. Throughout bodily examination, no seen indicators of swelling or discoloration famous within the legs or arms. Radial, brachial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses have been all palpable and common. No varicose veins or edema have been famous. Ankle-brachial index take a look at revealed a slight lower in blood circulation to the decrease extremities, indicating gentle peripheral artery illness.