Case Study
Henry Brusca is a 68-year-old, married father of 7 who was in relatively good health until 3 weeks ago. At that time, he visited the emergency room with the complaint of “just not feeling right.” His BP on admission was 170/118, so he was admitted to the coronary care unit with the diagnosis of uncontrolled HTN. His BP was controlled with medication, and he was discharged several days later. He is now being seen for follow-up care and management of HTN. Because Mr. Brusca is newly diagnosed with HTN, you will need to complete a history and thorough cardiovascular examination.
Case Study Findings
Biographical data:
■ 68-year-old white male.
■ Married, father of seven grown children.
■ Self-employed entrepreneur; BS degree in engineering.
■ Born and raised in the United States, Italian descent, Catholic religion.
■ Blue Cross/Blue Shield medical insurance plan.
■ Referral: Follow-up by primary care physician.
■ Source: Self, reliable.
Current health status:
■ No chest pain, dyspnea, palpitations, or edema.
■ Complains of fatigue, loss of energy, and occasional dizzy spells.
Past health history:
■ No rheumatic fever or heart murmurs.
■ No history of injuries.
■ Inguinal hernia repair.
■ Left ventricular hypertrophy revealed by electrocardiogram (ECG).
■ Hospitalized 3 weeks ago for HTN.
■ No known food, drug, or environmental allergies.
■ No other previous medical problems.
■ Immunizations up to date.
■ No prescribed medications except Vasotec 5 mg bid and weekly use of antacid for indigestion.
Family history:
■ Positive family history of HTN and stroke.
■ Mother had HTN and died at age 78 of a stroke.
■ Paternal uncle died at age 79 of MI.
Review of systems:
■ General Health Survey: Fatigue, weight gain of 60 lb over past 3 years.
■ Integumentary: Feet cold, thick nails, tight shoes.
■ Head, Eyes, Ears, Nose, and Throat (HEENT): Two dizzy spells over past 6 months.
■ Eyes: Wears glasses, no visual complaints, yearly eye examination.
■ Respiratory: “Short winded” with activity.
■ Gastrointestinal: Indigestion on weekly basis.
■ Genitourinary: Awakens at least once a night to go to bathroom.
■ Musculoskeletal/Neurological: General weakness, cramps in legs with walking.
■ Lymphatic: No reported problems.
■ Endocrine: No reported problems.
Psychosocial profile:
■ States that he does not have time for routine checkups. “I only go to the doctor’s when I’m sick. “Typical day consists of arising at 7 A.M., showering, having breakfast, and then going to work. Returns home by 6 P.M., eats dinner, watches TV till 11:30 P.M., but usually falls asleep before news is over. Usually in bed by 12 midnight.
■ 24-hour recall reveals a diet high in carbohydrates and fats and lacking in fruits and vegetables. Heavy-handed with salt shaker; salts everything. Admits that he has gained weight over the years and is 60 lb overweight.
■ No regular exercise program. States: “I’m too busy running my business.”
■ Hobbies include reading, crossword puzzles, and antique collecting.
■ Sleeps about 7 hours a night, but usually feels he is not getting enough sleep. Lately is more and more tired. Wife states that he snores.
■ Never smoked. Has a bottle of wine every night with dinner.
■ Works at sedentary job, usually 7 days a week. No environmental hazards in workplace.
■ Lives with wife of 45 years in a two-story, single home in the suburbs with ample living space.
■ Has a large, close, caring family.
■ Admits that running his own business is very stressful, but feels he can handle it alone and doesn’t need anyone to help him.
General Health Survey findings:
■ Well-developed, well-groomed 68-year-old white male, appears younger than stated age.
■ Sits upright and relaxed during interview, answers questions appropriately.
■ Alert and responsive without complaint, oriented x 4 (time, place, situation, and person).
■ Affect pleasant and appropriate.
■ Head-to-toe scan reveals positive arcus senilis, positive AV nicking and cotton wool, extremity changes including thin, shiny skin, thick nails, and edema.
■ Vital Signs
■ Temperature, 36.6 °C.
■ Pulse, 86 BPM, strong and regular.
■ Respirations, 18/min, unlabored.
■ BP: 150/90 mmHg.
■ Height: 180 CM.
■ Weight: 124 KG.
Cardiovascular assessment findings include:
■ Neck Vessels
■ Positive large carotid pulsation, +3, symmetrical with smooth, sharp upstroke and rapid descent, artery stiff, negative for thrills and bruits.
■ JVP at 30 degrees <3 cm, negative abdominojugular reflux.
■ Precordium
■ Positive sustained pulsations displaced lateral to apex, PMI 3 cm with increased amplitude.
■ Slight pulsations also appreciated at LLSB and base, but not as pronounced.
■ Negative thrills; cardiac borders percussed third, fourth, and fifth intercostal spaces to the left of the midclavicular line.
■ Heart sounds appreciated with regular rate and rhythm at apex S1 > S2 and +S4,at LLSB S1 > S2.
■ S2 negative split, at base left S1 < 2 negative split, at base right S1 < 2 with an accentuated
S2, negative for murmurs and rubs.
Questions:
1) What questions might be useful to elicit further details surrounding the Chest pain, using one of the common acronyms in this regard? (5 Marks)
2) From the subjective information you have obtained from Mr. Brusca’s history, what are his identifiable risk factors for heart disease? Which risk factors are modifiable and which are unmodifiable? (5 Marks)
3) List three priority nursing diagnosis for Mr. Brusca’s case, and cluster subjective and objective data that support each diagnosis. (3 Marks)
4) From the previous data, discuss the main issues of health promotion and disease prevention should the nurse discussed during health history and physical examination? (4 Marks).
5) Considering the relationship of the cardiovascular system to the respiratory system, what respiratory problems might Mr. Brusca have as a result of his cardiovascular disease? (3 Marks)

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