Cardiovascular Case Study Essay

 

 

Physical Assessment Case Study Template

Name:                                                                             

Week of Class (1-8):             

Body System focus area (i.e., cardiovascular):  Cardiovascular System                          Case Study: Case 3: A 15-year-old immigrant was brought to the clinic by her mother because client complains of shortness of breath, chest pains, diaphoresis and easy fatiguability. She claims she has had on and off bouts of tonsillitis since she was a child that resulted in tonsillectomy surgery when she was 12. Last week, she was unable to participate in the cheer leading tryouts because of knee pain and a rash that she noticed on her trunk for the past 2 weeks.

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

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

1. What is the client’s chief complaint?

The client’s chief complaint is “shortness of breath, chest pains, diaphoresis and easy fatiguability.”

 

2. What questions would you ask the client?

 

• HPI (history of present illness): how long have you had the chest pains? When did you start having breath shortness, sweating, and feeling fatigued? What other symptoms are you experiencing? What triggers the chest pains, breath shortness, or fatigue? What are you using to relieve the symptoms?
• ROS (review of systems): General; have you lost weight? Are you experiencing fever or chills? HEENT: Do you have visual loss, blurred vision, or double vision? Ears, Nose, Throat: Are you experiencing hearing loss, sneezing, congestion, runny nose, or sore throat? Cardiovascular: Do you have chest pains, pressure, or discomfort? Respiratory: are you experiencing shortness of breath, cough, or sputum? Skin: have you had a rash or experienced itching?
• Medical/Surgical/Psych History: have you ever had a major surgery, and when was that? Are all your immunizations up to date? Do you have an underlying medical condition?
• Family History: Do any of your immediate family members have a chronic illness? What is the reason for the death of your deceased first-degree relatives, if any? Do you have siblings with any chronic diseases?
• Allergies: are you allergic to any medications? Do you have any known food or environmental allergies?

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3. What physical examinations would you include?

 

Body System	Include? ✓   (yes) or – (not indicated)	Notes
General survey	✓	An overall observation of the patient Weight and height measurements Vital signs
HEENT (head, eyes, ears, nose, throat/thyroid)	✓	Inspection Skull palpation Observe and inspect the eyes Inspect the ears, neck, nose, and throat
Cardiovascular	✓	Auscultate heart sounds (stethoscope to actual skin) Palpate the peripheral pulse
Peripheral Vascular
Breasts
Lymphatic
Pulmonary	✓	Auscultate lung sounds (stethoscope to actual skin) – anterior and posterior Percussion, observe for any accessory muscle use.
Gastrointestinal/Abdominal
Genitourinary/Pregnancy
Integumentary
Musculoskeletal
Neurological

 

4. What are pertinent positive physical assessment findings?

Pertinent positive physical assessment findings are the findings that point to the diagnosis (Parker & Parker, 2019). They mainly result from the symptoms mentioned by the patient. In this case, the pertinent positive findings that will be used to rule in the diagnosis include shortness of breath, fatigue, chest pains, and diaphoresis.

 

5. What are the pertinent negative physical assessment findings?

In this case, the pertinent negative physical assessment findings include fever, chills, rash, and knee pain.

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

Pulmonary Embolism: a condition whereby a blood clot blocks one of the pulmonary arteries (Freund et al., 2022). The condition is characterized by chest pains/discomfort and breathlessness. In this case, the client presents with shortness of breath and chest pains; thus, the condition is differential. It Is, however, ruled out since the patient does not have a cough, which is one of its symptoms.

Pneumonia: the patient, in this case, presents with fatigue, shortness of breath, and chest pains, which are associated with pneumonia. However, the condition is ruled out since the patient has no fever.

Heart attack: the patient presents with chest pains, shortness of breath, sweating, and unexplained fatigue, common in heart attacks. Therefore, the condition is differential. However, it is ruled out due to the absence of pain in the back, neck, arms, or stomach.

7. What is your primary diagnosis?

The primary diagnosis in this case is angina. Angina involves reduced blood flow to the heart muscles (Hermiz & Sedhai, 2022). It is characterized by chest pains, shortness of breath, and unexplained sweating. The patient presents with all these symptoms, thus the primary diagnosis.

 

8. What is your treatment plan?

The diagnostic procedures and lab tests that were used to confirm the diagnosis include a 12-lead electrocardiogram (ECG), chest X-ray, complete blood count (CBC), and basic metabolic profile (BMP). Client education, in this case, includes dietary and exercise lifestyle modifications. It is also vital to educate the patient on risk factors and alarming symptoms that should be monitored to avoid cardiac events. Hermiz and Sedhai (2022) note that angina treatment aims at managing symptoms and slowing the progression of cardiac events. Therefore, pharmacotherapy would include Antianginals, beta-blockers, and Calcium channel blockers. A follow-up is needed after two weeks for patient review.

 

References

Freund, Y., Cohen-Aubart, F., & Bloom, B. (2022). Acute Pulmonary Embolism: A Review. JAMA, 328(13), 1336–1345. https://doi.org/10.1001/jama.2022.16815

Hermiz, C. & Sedhai, Y.R. (2022). Angina. In: StatPearls [Internet]. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK557672/

Packer, C. D., & Packer, C. D. (2019). Pertinent Positives and Negatives. Presenting Your Case: A Concise Guide for Medical Students, 57-71. https://doi.org/10.1007/978-3-030-13792-2_5

Physical Assessment Case Study Template

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Name:                                                             

Week of Class (1-8):          

(copy/paste here please)

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

 

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? ✓   (yes) or – (not indicated)	Notes
General survey	✓
HEENT (head, eyes, ears, nose, throat/thyroid)
Cardiovascular	✓	Auscultate heart sounds (stethoscope to actual skin)
Peripheral Vascular
Breasts
Lymphatic

 

Pulmonary	✓	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)?

 

 

o o o

 

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