Case Study: Cardiovascular

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?

 

  1. What questions would you ask the client? 

 

  • HPI (history of present illness) 
  • ROS (review of systems)
  • Medical/Surgical/Psych History
  • Family History
  • Other

 

  1. What physical examinations would you include?
Body System

Include? 

ü (yes) or – (not indicated)

Notes
General surveyü 
HEENT (head, eyes, ears, nose, throat/thyroid)  
CardiovascularüAuscultate heart sounds (stethoscope to actual skin)
Peripheral Vascular  
Breasts  
Lymphatic  
PulmonaryüAuscultate lung sounds (stethoscope to actual skin) – anterior and posterior
Gastrointestinal/Abdominal  
Genitourinary/Pregnancy  
Integumentary  
Musculoskeletal  
Neurological  

 

  1. What are pertinent positive physical assessment findings?

 

  1. What are the pertinent negative physical assessment findings?

 

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

 

  •  
  •  
  •  

 

  1. What is your primary diagnosis?

 

  1. 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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