Case study: cardiovascular

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Case 1: An 89-year-old female complains of a “stabbing chest pain” and points to the area just below her scapula at the right mid-clavicular line. She states that she had an upper respiratory infection last week that “just seems to hang on.” No other complaints. 

Physical Assessment

Case Study Template

Name: ________________________________________

Week of Class (1-8): ______

Body System focus area (i.e., cardiovascular): _____________________________

Case Study: (copy/paste here please)

Note: Include in-text citations as needed (author, year).

Questions (if data is unavailable, indicate “unavailable”):

1. What is the client’s chief complaint?

2. What questions would you ask the client?

· HPI (history of present illness)

· ROS (review of systems)

· Medical/Surgical/Psych History

· Family History

· Other

3. What physical examinations would you include?

Body System

Include?

ü (yes) or – (not indicated)

Notes

General survey

ü

HEENT (head, eyes, ears, nose, throat/thyroid)

Cardiovascular

ü

Auscultate heart sounds (stethoscope to actual skin)

Peripheral Vascular

Breasts

Lymphatic

Pulmonary

ü

Auscultate lung sounds (stethoscope to actual skin) – anterior and posterior

Gastrointestinal/Abdominal

Genitourinary/Pregnancy

Integumentary

Musculoskeletal

Neurological

4. What are
pertinent positive physical assessment findings?

5. What are the
pertinent negative physical assessment findings?

6. What are at least 3 differential diagnoses (use Up-to-Date App if needed)?

·

·

·

7. What is your primary diagnosis?

8. What is your treatment plan?

· Diagnostic procedures

· Labs

· Client education (including lifestyle modifications, if applicable)

· Pharmacotherapy (including complementary and alternative therapies)

· Health promotion (preventative care, anticipatory guidance)

· Follow-Up

References

(within last 5 years, scholarly, include clinical practice guidelines if available)

APA format please, at least one reference

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