SYSTEM ASSESSMENT PRESENTATION 2024

CARDIOVASCULAR ASSESSMENT:
Ischemic Heart Disease, Aortic Valve Stenosis

SUBMITTED BY:
BSN 1 – PARSE GROUP 5
Santillan, Sophia Lorraine
Sarita, Rechile
Sause, Jehzielle Kae
Sudayan, Marielle
Suyo, Quinn
Untolan, Sophie
Vingno, Hershey

SUBMITTED TO:
Shiela Marie Amacio, RN
I. ANATOMY & PHYSIOLOGY

The heart pumps blood and oxygen throughout the body, distributing waste products like
carbon dioxide back to the lungs. It consists of four chambers, valves, and heart walls, with the
septum dividing them.

The heart walls have three layers:

● Endocardium: Inner layer.

● Myocardium: Muscular middle layer.
● Epicardium: Protective outer layer.

The myocardium controls the heart pump's contractile action. The heart muscle is
composed of cardiomyocytes and has specific cellular and physiological features that allow it to
generate force and maintain adequate tissue and organ perfusion throughout the body.

Heart chambers

The heart has four separate chambers, consisting of two atria on the top (atrium, plural
atria) and two ventricles on the bottom, one on each side of the heart. The right atrium
receives oxygen-poor blood from the body through the superior vena cava, which carries blood
from the upper body, and the inferior vena cava, which brings blood from the lower body. It then
pumps this blood to the right ventricle, which in turn pumps it to the lungs via the pulmonary
artery for oxygenation. Once the blood is reloaded with oxygen in the lungs, the pulmonary
veins carry it to the left atrium, which then pumps it to the left ventricle. The left ventricle,
slightly larger than the right, is responsible for pumping oxygen-rich blood to the rest of the body.

Pulmonary circulation transports deoxygenated blood to the lungs for oxygen

absorption, while systemic circulation moves blood throughout the body. In systemic
circulation, oxygenated blood is carried from the left ventricle through the arteries to the
capillaries in the body's tissues. From the tissue capillaries, deoxygenated blood returns through
a system of veins to the right atrium of the heart. Heart valves, functioning as doors between
the heart chambers, open and close to regulate blood flow and ensure it moves in the correct
direction, preventing any backflow.

The heart's atrioventricular valves open between the upper and lower chambers,
including the tricuspid valve, which separates the right atrium and right ventricle, and the
mitral valve, which separates the left atrium and left ventricle. The semilunar valves open
when blood flows out of the ventricles, including the aortic valve, which opens to allow blood to
flow from the left ventricle into the aorta, and the pulmonary valve, which opens to allow blood
to flow from the right ventricle into the pulmonary arteries. Blood vessels play a crucial role in
circulation, with arteries carrying oxygen-rich blood from the heart to the body's tissues, except
for the pulmonary arteries that carry oxygen-poor blood to the lungs. Veins return oxygen-poor
blood back to the heart, while capillaries are small vessels where the exchange of oxygen-rich
and oxygen-poor blood occurs. The aorta, a major artery, carries oxygen-rich blood away from
the heart to the rest of the body, serving as the main highway for blood circulation, delivering
oxygenated blood to all organs and tissues. Its Aortic root serves as the body's water main.
Aortic dissection occurs when weakened aorta walls tear, increasing risk of aneurysm.

Carotid artery Circulation

One of several arteries that supply blood to the head and neck. Of the two common
carotid arteries, which extend headward on each side of the neck, the left originates in the arch
of the aorta over the heart; the right originates in the brachiocephalic trunk, the largest branch
from the arch of the aorta. Each common carotid artery divides into an external and an internal
carotid artery.

Each internal carotid artery ascends through the carotid canal in the temporal bone into
the cranial cavity. It gives off an ophthalmic branch to the eyeball and other contents of the orbit
and then divides into the anterior and middle cerebral arteries. The internal carotid arteries,
together with the vertebral arteries, which are the arteries of primary supply for the brain, are
distinguished by lying at some depth from the surface in their course to the organ, by having
curves or twists in their course, and by having no larger collateral branches.

The external carotid artery ascends through the upper part of the side of the neck and
behind the lower jaw into the parotid gland, where it divides into various branches. The external
carotid artery gives off the following branches: superior thyroid to the larynx and thyroid gland,
lingual to the tongue and sublingual gland, facial to the face, palate, tonsil, and submaxillary
gland, occipital to the sternomastoid muscle and back of the scalp, posterior auricular to the
back of the ear and the adjacent part of the scalp, superficial temporal to the scalp in front of
the ear and, by its transverse facial branch, to the back part of the face, maxillary, giving
muscular branches to the muscles of mastication, meningeal to the dura mater, dental to the
teeth, and other branches to the nose, palate, and tympanum, and ascending pharyngeal, which
supplies the pharynx, palate, tonsils, and dura mater.

Coronary arteries

The coronary arteries provide nutrition to the heart. Coronary circulation involves blood
flow in arteries and veins that supply the heart muscle, with arteries supplying oxygenated blood
and veins draining deoxygenated blood. These arteries run along the heart's surface. They
serve the heart and include the following:

The left coronary artery divides into two branches: the circumflex artery and the left
anterior descending artery (LAD). The circumflex artery supplies blood to the left atrium and
the side and back of the left ventricle, while the LAD supplies blood to the front and bottom of
the left ventricle and the front of the septum. The right coronary artery (RCA) supplies blood to
the right atrium, right ventricle, the bottom portion of the left ventricle, and the back of the
septum.

Coronary Artery Circulation

It is part of the systemic circulatory system that supplies blood to and provides drainage
from the tissues of the heart. In the human heart, two coronary arteries arise from the aorta just
beyond the semilunar valves; during diastole, the increased aortic pressure above the valves
forces blood into the coronary arteries and then into the musculature of the heart.
Deoxygenated blood is returned to the chambers of the heart via coronary veins; most of these
converge to form the coronary venous sinus, which drains into the right atrium.

One of two blood vessels that branch from the aorta close to its point of departure from
the heart and carry oxygen-rich blood to the heart muscle. Both arteries supply blood to the
walls of both lower chambers (ventricles) and to the partition between the chambers. The right
coronary artery supplies blood to the right upper chamber (atrium), while the left supplies the left
atrium. Blockage of any branch of the coronary arteries causes death of a portion of the heart
tissue when it is deprived of oxygen-rich blood (see coronary heart disease).

Disease focused - Ischemic Heart Disease, and Aortic Valve Stenosis.

Ischemic Heart Disease

Ischemic heart disease refers to heart weakening caused by reduced blood flow to the
heart. Typically, this reduced blood flow is the result of coronary artery disease, a condition that
occurs when the coronary arteries narrow. Ischemic heart disease may also be called cardiac
ischemia or ischemic cardiomyopathy.
Affected Area of the Heart (Ischemic Heart Disease)
Ischemic heart disease affects the heart's coronary arteries. These are the blood vessels
that supply oxygenated blood to the heart muscle. Ischemic heart disease develops when
plaque accumulates in the walls of the arteries, narrowing the openings and limiting blood flow
to the heart. This can lead to angina, shortness of breath, and other symptoms.

Ischemic heart disease is a pathophysiological condition caused by a mismatch between

the myocardial oxygen demand and supply. This occurs when blood flow to the heart is reduced,
preventing the heart muscle from receiving enough oxygen.

The reduced blood flow is usually the result of a partial or complete blockage of the
heart's arteries (coronary arteries). In general, the pathology relates to large coronary arteries,
and stenosis reduces the coronary artery in the same way there is a presence of
vasoconstriction.

Myocardial ischemia occurs when blood flow to the heart muscle (myocardium) is
obstructed by a partial or complete blockage of a coronary artery by a buildup of plaques called
atherosclerosis.

Aortic Valve Stenosis

When the aortic valve narrows, it prevents blood from flowing from the left ventricle to
the ascending aorta during systole, a condition known as aortic stenosis (AS). Idiopathic
degenerative sclerosis with calcification, and a congenital bicuspid valve are among the causes.

Affected Area of the Heart (Aortic Valve Stenosis)

Aortic valve stenosis occurs when the aortic valve, which connects the heart's left
ventricle to the aorta (the vessel that transports oxygenated blood away from the heart),
narrows. This can cause pressure buildup in the left ventricle, resulting in symptoms like
shortness of breath, chest pain, and fatigue.

Generally most common in degenerative adults (which is 70 years older or considered

as elder). Then progresses into the constant usage over the years that disrupts the inner
structure of the valve. Continuously would begin calcification or a build-up of plaque, also known
as atherosclerosis which is the thickening or hardening of arteries caused by the accumulation
of plaque in the inner lining of an artery.

To proceed, then it causes delayed flow through the aortic valve, and the left ventricle
contracts harder to pump blood causing a high left ventricle-aorta pressure gradient that drives
into the aorta.

Over time, this forceful contraction causes a concentric left ventricle of a myocardial
hypertrophy. Then this proceeds to a pressure overload that causes pulmonary congestion
which then causes a symptom of dyspnea. Whereas, the angina on exertion is caused by the
forceful contraction that causes concentric left ventricle myocardial hypertrophy.
II. NURSING HISTORY

A. BIOGRAPHIC DATA
Name: J. R. S.
Address: Carmela Valley Homes, Talisay City, Negros Occidental
Age: 75 years old
Birthdate: March 3, 1949
Birthplace: Bacolod City, Negross Occidental
Sex: Male
Civil Status: Widowed
Nationality: Filipino
Occupation: Retired Postmaster
Religion: Born Again Christian
Usual Source of Medical Care: Pension and remittance from daughter abroad
Attending Physician(s): Dr. R
Source(s) of Information: Primary Source - the patient himself for subjective data.
Secondary Source - Grand daughter, Son & Daughter for historical data and
other important data.

B. CHIEF COMPLAINT/ DIAGNOSIS

The patient often complains about chest pain in the left side characterized by
dyspnea. With further investigation and consultation from a cardiovascular specialist, Dr.
Rallios, the patient was diagnosed with ischemic heart disease which additionally from a
recent incidental finding of 2023, his diagnosis involves severe aortic stenosis.

C. HISTORY OF PRESENT ILLNESS

The patient, Sir J.R.S., has experienced variable onset of dull central chest pain
that is non-radiating in nature that started in 2017 up until recent, which means the chief
complaints and diagnosis started at the age of 68 onwards. Which then has been
medically diagnosed by Dr. R as an ischemic heart disease. However, unbearable
symptoms such as chest pains have been alleviated due time, after 1 year of
medications. Triggering factors include excessive heavy workload activity such as lifting
heavy objects, being in the heat for too long, and no rest while exercising for a long
period. And the following triggering factors are relieved by rest and medication.

The patient also has undergone 2D Echocardiography, the findings of the

cardiovascular specialist was that one valve (aortic valve) of the heart has trouble
functioning which then was medically diagnosed as “Aortic Valve Stenosis”.

D. HISTORY OF PAST ILLNESS(ES)

The patient experienced a long history of hypertension and ischemic heart
disease. This was acquired due to old age, and not by birth though hereditary factors
may be considered. The patient has no allergies of any kind as well as any presence of
childhood diseases. The patient did not undergo any surgical intervention but rather
through conservative management through medication, diet and lifestyle changes. In
addition, there was an incidental finding of an aortic stenosis on his sonography
(sonography was unobtained) after a vehicular accident, which was further investigated
through a 2D Echocardiography on his aortic arch dated November 2023. This was done
after his vehicular accident.
 E. HEREDOFAMILIAL DISEASE(S)
DISORDER MATERNAL PATERNAL
DM (both types) - -
Hypertension + (Mother) + (Father)
Asthma - -
Cancer - -
Food and Drug Allergies - -

F. LIFESTYLE
The lifestyle of the patient after the diagnosis involved walks and cycles at least
30 mins per day. The patient eats more fish than red meat, eats small portions of poultry,
and eats more fruits and vegetables. The patient does not exhibit any smoking or any
alcohol habits and activities. To further expound the lifestyle of the patient,
Nutritional and Metabolic Pattern The nutritional diet of the patient involves
eating fruits and vegetables at least twice a day
depending on the availability of the said food.
Patient doesn’t monitor the amount of saturated
fats and rarely eats a meal prepared by the
restaurant.

Additionally, the patient drinks caffeine twice

a day. And the patient exhibits extreme
consciousness with whatever he partakes in his
body.

Activity-Exercise Pattern The activity in the morning of the patient

involves walking, stretching, and cycling if the
weather isn’t hot. Initially it was for an hour but
due to the extreme hot weather it was reduced
to 30-45 mins. On occasions, the patient also
involved himself with farming and gardening in
his daily activities.

Effects of chest pain usually occur during the

1 hour mark.

Sleep-Rest Pattern The patient expresses no difficulty in falling

asleep and no difficulty staying asleep.

G. SOCIAL DATA
The patient currently lives with his daughter and her family. The patient also is an
active member of a Christian church as a chaplain, choir member, and a life group
member. To expound the patient’s social data,
Role-Relationship Pattern The patient is monitored and feels supported
 by his family through physical support such as
heavy household tasks through his eldest son,
daily nutrition and monthly check ups through
his eldest daughter, financial and emotional
support through his second daughter, and
lastly, medical advice through his youngest
son.

When in hospitalization or any healthcare

appointments, his children support him in
every way they can that includes financially,
stability, and medical topics.

Additionally, his peers in church also come

to visit him whenever he is hospitalized and
they come to check up on him from time to
time.

In terms of roles, the patient is still able to

perform tasks as a grandfather, driving his
grandchildren to school, gardening at his farm,
and doing outreach tasks in his church.

H. PSYCHOLOGICAL DATA
No history of psychological or mental health issues. To expound the
psychological data of the patient,
Health Management and Health Perception The patient exhibits adequate knowledge
and understanding of his own personal
medical condition. Along with the basic
knowledge of the causative factors of heart
disease, and immediate remedies whenever
symptoms such as chest pains occur. The
patient also mentioned that he adjusts the time
to take his medications whenever he
accidentally misses the scheduled time to take
said medications.

In terms of maintenance, the previous high

blood pressure drastically decreased lower
than normal so the patient expressed his
concern to lower the dosage which means the
patient is currently having a balanced blood
pressure due to maintenance medications.

Cognitive-Perceptual Pattern The patient is oriented with time, date,

people and place. There seems to be no
deficiency in cognitive abilities such as the
patient continuing to exhibit a stable attention
 span, practicing logical reasoning, critical
thinking and decision-making.

However there seems to be an extremely

mild deficient memory attainment. The patient
constantly forgets where he puts his glasses,
sometimes forgets to drink their medicines at
the scheduled time, and needs to write down
every task to refrain from forgetting.

Self-Perception/ Self Concept Pattern The self-perception of the patient can be

observed through his opinion of himself which
is still a functioning human being. The patient
doesn't think himself to be deficient in
everyday tasks as he can still drive, handle
money and more at such an old age.

Coping/Stress Tolerance The patient treats his spending time with

his grandchildren as a “stress-reliever”. The
patient also explained that taking a coffee and
having a nature break is one of the best
coping strategies he does daily from either
medical or personal stresses.

Since the patient was advised to

experience less stress, he makes an effort to
avoid stress at all costs. So his conscious
body, whenever stress persists, he alleviates it
immediately by taking a snack, taking a break,
and relaxing.

I. PATTERNS OF HEALTHCARE
Obtained by Subjective Interview Assessment
The patient explained the use of medications whenever specific symptoms occur, for
example atenolol for the presence of chest pain or angina. If the symptoms continue to persist,
the patient checks his blood pressure, whenever it is high, he takes additional medications and
takes a nap afterwards. The patient consistently goes for a regular check up every 2-3 months
along with a family member to take note of his status. If within a time period that his regular
check up was recent and he feels his body weakens, he takes a laboratory diagnostic test to
identify which parts of the laboratory findings have increased its abnormalities. After that
identification, his children then decide whether it could be treated with medicine or if a check up
is required since 2 of his children are nurses. So far, the patient verbalized that he has not yet
experienced being in a critical state since whenever symptoms persist, he takes medications
and rest instantly.
 Medications prescribed by Dr. R as of November 26, 2023. The information was
obtained through the patient’s personal medication profile summary that involve:

ONGOING MEDICATION:

Sunday & Saturday

Monday, Wednesday, and Friday

Tuesday & Thursday

MEDICATIONS
1. Amlodipine (calcium channel blocker). It lowers blood pressure by relaxing the blood
vessels so the heart does not have to pump as hard.The side effect involves swelling of
feet.
2. Atenolol (beta-blocker) affects the heart and circulation. Atenolol is used to treat angina
(chest pain) and hypertension (high blood pressure).
3. Diltiazem (calcium-channel blocker). It works by relaxing the blood vessels so the heart
does not have to pump as hard. Diltiazem also increases the supply of blood and oxygen
to the heart. Diltiazem oral is used in adults alone or in combination with other medicines
to treat hypertension (high blood pressure) or symptoms of angina (chest pain).
Side effects: swelling, trouble breathing, headache, dizziness, weakness, and slower
heart rate.
4. Clopidogrel (antiplatelet) used to lower the risk of having stroke, blood clot, or serious
heart problem after you’ve had a heart attack, severe chest pain (angina), or circulation
problems.
5. Ranolazine (Brand Name: Ranexa) taken 500mg/tab with dosage of ½ tab every day of
the week at 6am and 6pm; is used to treat chronic angina (ongoing chest pain or
pressure that is felt when the heart does not get enough oxygen).
6. Sulodexide belongs to the class of heparin group. Used in the treatment of thrombosis.
Treatment of peripheral vascular insufficiency; patients at risk of thrombosis eg,
peripheral vascular insufficiencies, MI & cerebral transient ischemic attack or strokes;
diabetic retinopathy.
7. Trimetazidine is classified as a coronary vasodilator. Vasodilators open blood vessels.
Trimetazidine is used to treat angina (chest pain), heart failure, and peripheral heart
disease (PHD). Side effects: discomfort on exertion, drowsiness, heart palpitations,
changes in vision.
DISCONTINUED MEDICATION
1. Rosuvastatin (statin) taken 20mg/tab with dosage of 1 tablet every bedtime on
Monday, Wednesday, and Friday; is used to treat high cholesterol and prevent heart
attacks and strokes. It lowers the level of “bad” cholesterol (LDL) and lowers the level of
fat in the blood (triglycerides).

2. Fenofibrate is used with a cholesterol-reducing diet to lower high cholesterol and high
triglyceride (fatty acid) levels in the blood. It works by increasing the breaking down and
removal of triglycerides from the blood.

The reason for discontinuation of the medications mentioned is due to the

patient’s current laboratory results, it has been found out that the previous high
cholesterol has lowered into normal values. However, if there is a situation that it
elevates, the doctor suggested continuing this medication again after check up.

III. PHYSICAL ASSESSMENT

A. BASELINE DATA
Height: 5’7 Weight: 58 kg
Vital Signs:
Date/Time BP T P R

April 23, 2024 124/80 36.8 C 71 15

B.OVER-ALL APPEARANCE OF THE PATIENT

SKIN The patient has a normal skin color, and there are no
signs of pallor and redness, the texture is also normal
and having a warm touch temperature, no presence of
lesions and turgor is also Senile turgor. The condition of
the nail is currently well-groomed and has a normal
color, and no signs of abnormalities.

HEAD For the scalp, there is slight discoloration due to motor

accident, and slight alopecia in the parietal area of the
head and in the face, the patient has the presence of
spot-like hyperpigmentation. Over-all, the head has no
abnormalities.

EARS For the external ear there is a slight tingling sensation

sometimes, but can hear well at a near proximity. And
the overall appearance of the ear has no signs of
abnormalities.

EYES For the eyeballs, there is a slight discharge or could be

 termed as watery eyes. The sclera is white in color
which is normal and conjunctiva is normal with a
presence of pink color. The vision sometimes is cloudy
without eyeglasses, and the pupils are equally rounded,
reactive to light and accommodation. There is a bluish
ring around the iris which is normal in people with old
age and overall appearance is normal.

NOSE The patient has a slightly lower sense of smell, however

can smell strong scents like coffee, etc. There is no
deviated septum and no discharge, overall appearance
is normal.

MOUTH The condition of the lips has no lesions and no signs of

dehydration. The patient expresses a slight difficulty
swallowing, and the patient has 5 dentures. Overall
appearance of the mouth is normal.

NECK There is no inflammation of lymph nodes, range of

motion is normal as well as the strength. And the texture
of the neck has senile turgor. Overall appearance is
normal, therefore no signs of abnormalities.

CHEST For the chest, there is no signs of adventitious sound,

has a normal heart rate, and there are no lesions. No
signs of abnormalities, therefore the overall appearance
is normal.

UPPER EXTREMITIES For the upper extremities, the range of motion appears
to be normal as well as the strength. There is no
presence of nodules and lesions, the overall
appearance of the upper extremities is normal.

LOWER EXTREMITIES For the lower extremities, the range of motion is normal
as well as the strength. It was found that the patient has
1+ edema on his left foot, and the overall appearance is
normal except for the swelling of the left foot.

C. SYSTEM ASSESSMENT
I. PRECORDIUM ASSESSMENT RESULTS

1. Locate the intercostal spaces.

2. Locate the midsternal line.

3. Locate the midclavicular line.

4. Locate the anterior axillary line.

5. Palpate the aortic area. In palpation, the following areas are

6. Palpate the pulmonic area. normal, therefore no presence of any
abnormalities such as tumors or
7. Palpate the Erb’s point. masses.

8. Palpate the tricuspid area.

9 Palpate the mitral area.

10 Palpate for heaves and/or thrills. In palpation, the chest area is

negative for heaves and thrills.

11 Percuss the heart’s borders. In percussion, the border sounds are

normal.

To expound, percussion over the

base (upper border) of the heart by
deep percussion over the left and
right 2nd intercostal space medial to
midclavicular line. Normally the 2nd
spaces are resonant.

Percussion to the right of the sternum

at the intercostal space above that
the upper border of liver or at the 4th
intercostal space in cases with lung
hyperinflation. Normally there is no
dullness to the right of the sternum. .

12 Auscultate the aortic area. In auscultation, the patient’s chest

exhibited no adventitious or abnormal
13 Auscultate the pulmonic area. sounds. Therefore, the findings are
normal.
14 Auscultate the Erb’s point.

15 Auscultate the tricuspid area.

16 Auscultate the mitral area.

17 Locate where the S1 is best heard

18 Locate where the S2 is best heard.

II. PERIPHERAL VASCULAR ASSESSMENT

1 Inspect the extremities’ skin integrity Senile turgor - poor elasticity which
the findings can be interpreted as
normal due to old age.
2 Inspect for scattered sensations. The patient was able to identify
whether the object was sharp or dull,
indicating there is no presence of
scattered sensation, which means
that there is no damage to the
sensory nerve indicating that it is
normal.

3 Palpate skin for temperature. Balanced in temperature in

comparison bilaterally which can be
interpreted as a normal finding.

4 Assess for mobility of extremities. The patient’s score is 5, which means

there is a full range of motion with no
assistance which can be interpreted
as a normal finding.

5 Assess for presence of edema. Has 1+ edema on his left foot.

To expound, it is a side effect of the

medicine, “amlodipine”, a calcium
channel blocker to regulate the blood
pressure. Since, the patient is
hypertensive along with ischemic
heart disease.

6 Assess for presence of superficial veins. There is no presence of superficial

veins

7 Assess for presence of jugular vein distention. There is no presence of jugular vein
distention.

8 Assess head and neck pulses for rate, rhythm, and The grading for the pulse is 2 which is
quality. easy to palpate and not easily
obliterated with pressure. Indicating a
normal rhythm, rate and pulses

9 Assess upper body pulses for rate, rhythm, and Rhythm, rate and pulses is 1, which is
quality. difficult to palpate, the rhythm is weak
and easily obliterated with pressure.
Indicating a slightly abnormal rhythm,
rate, and pulses.

To expound, in terms of maintenance,

the previous high blood pressure
drastically decreased lower than
normal which is a causative factor for
this finding.

10 Assess lower body pulses for rate, rhythm, and The grading for the pulse is 2 which is
 quality. easy to palpate and not easily
obliterated with pressure. Indicating a
normal rhythm, rate and pulses

11 Perform Allen’s test. In assessing the arterial blood flow of

the hand, there was a return of blood
flow in both ulnar and radial side
which indicated a normal finding.

12 Perform Buerger’s test. The findings involve no pallor

appearance of the feet upon
elevation, therefore indicating a
normal finding.

13 Perform capillary refill test. In performing the capillary refill test,

the color of the nail was able to return
to its normal pinkish color in a few
seconds indicating good circulation
with good levels of oxygen which
indicates it is a normal finding.

14 Perform phlebitis test. Negative for phlebitis and deep vein

thrombosis.

15 Assess for Homan’s sign. Normal both legs, therefore the

patient doesn’t have any presence of
deep vein thrombosis in the leg.

16 Auscultate carotid artery for presence of bruits. Bruit present due to Atheroma caused
by the clinical diagnosis of Aortic
Valve Stenosis.

To expound, bruit present is an

indication of carotid artery stenosis
secondary to plaque formation.
Plaque formation is also due to high
cholesterol.

17 Check the blood pressure. Normal findings of blood pressure.

right arm 118/74 - left arm 124/80
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