Patient Information

Patient: Mr. Agboka

Ethnocultural background: African descent
Age: 49

Related Clinical Chapter

Chapter 21: Peripheral Vascular System and Lymphatic System

Mr. Agboka, a 49-year-old man of African descent who is a schoolteacher, is brought to the
emergency department for evaluation of chest pain. He was shoveling snow from his driveway
and finished half the work when he suddenly became short of breath and dizzy. He felt chest pain
that he describes as "crushing and heavy" and ran down his left arm.
He went inside, rested on the couch, and took two of his wife's nitroglycerin tablets. After 10
minutes, the pain subsided somewhat, but his wife insisted on calling an ambulance. He is very
upset and states, "I know what it is. My dad died of a heart attack when he was 53 and now it's
my turn." While Mr. Agboka is having an ECG performed, his wife takes you aside and tells you
that he had been treated for hypertension, high cholesterol levels, and diet-controlled diabetes but
that he has refused all medication for the past year. He eats what he wants and does not get much
exercise during the school year. According to his wife, Mr. Agboka is about 23 kg (50 pounds)
overweight. She also tells you that he quit smoking last summer. She says that she tries to cook
healthy foods for him, but he "gets what he wants" when he is not at home, and uses the salt
shaker freely.
You begin your assessment. His apical pulse is 118 beats per minute and regular; blood pressure
is 166/98 mm Hg; and his level of chest pain is a "2" on a scale of 1 to 10. No visible pulsations,
heaves, or lifts are evident over his precordium. No cyanosis is observed, and an apical impulse
is palpable at the fifth left intercostal space. He states that the nitroglycerin tablets took away the
severe pain, but now his chest just "aches". When he describes his previous pain, he clenches his
fist to illustrate the pain. His skin is moist, and his clothes are damp from perspiration. He feels
nauseated but has not vomited. He denies continued shortness of breath and pain elsewhere. He
seems very upset and anxious and asks for his wife to be at his side.

Answer the following questions in small groups.

1. What do you think is the cause of Mr. Agboka’s chest pain? Provide support for
your answer.
.

2. Does Mr. Agboka have any cardiac risk factors? If so, specify them.
Correct Answer
Mr. Agboka's risk factors for coronary artery disease include the following:

 Elevated serum cholesterol levels

 Elevated blood pressure (history of hypertension)
 A history of diabetes
o Obesity
 A history of cigarette smoking
 A low activity level. He also has a positive family history of cardiac disease (his father).

1
 3. Are there any cultural considerations to keep in mind in Mr. Agboka’s case?
Correct Answer
Adults of African descent have a higher prevalence of strokes and heart disease than
adults of any other ethnnocultural group. They also have lower serum cholesterol levels,
and a higher incidence of diabetes, than do some other ethnocultural groups.

4. Describe the best places to listen for normal heart sounds.

Correct Answer
The S1 heart sound can be heard over the entire precordium, but it is loudest at the apex.
It can be heard with the diaphragm with the patient in any position and is heard equally
well during inspiration and expiration. The S2 heart sound can also be heard over the
entire precordium with the diaphragm, but it is loudest at the base.

Case Study Update:

After his condition has stabilized, you assist Mr. Agboka in removing his boots. When you
remove his socks, you see an ulcer on the lateral side of his left great toe. When you ask him
about it, he looks surprised and says that he has not felt it. Further assessment reveals the
following:

Mr. Agboka has had calf pain, which he describes as "cramps," when he walks long distances,
such as from his classroom to his car. The pain is relieved when he sits down. He also avoids the
stairs for this reason. The skin of his lower legs is cool, thin, and shiny, and hair is absent. The
nails are thick and ridged. The ulcer measures 1.5 cm in length and 1 cm in width, and is covered
with brownish-black tissue that does not ooze

5. On the basis of these assessment findings, what type of problem does this ulcer
reflect?
Correct Answer
These findings are consistent with chronic arterial symptoms. The ulcer is an ischemic
ulcer, resulting from atherosclerotic and arteriosclerotic changes, and it is probably
hastened by poorly controlled diabetes.

6. What further assessments should you perform?

Correct Answer
Further assessments should include assessment of peripheral pulses, either by palpation or with a
Doppler device, and palpation of the legs to compare skin temperature, presence or absence of
edema, color changes on elevation of the legs (noting the color of the soles of his feet, since he is
dark-skinned), and sensation.