Cardiology Case Study

Introduction

The following scenario will take you through the case of a patient presenting with a cardiac complaint in an acute care setting.

When evaluating a patient in the acute care setting, it is essential to obtain information in an efficient manner. Focus your assessment and initial evaluation on findings that are the most life-threatening and those which are pertinent to the case provided.

Begin by listening to the case background below.

Reminders:

Have your course resources available (textbook, slides, online resources)
Download the Cardiology Case SOAP note template to fill in while completing this case.
Take notes during the audio portions of the case
Allow at least 1 hour to complete this case

Initial Patient Evaluation

It is now time to document your findings in the cardiology SOAP note provided in your assignment instructions.

Initial Physical Examination

Select the five key systems you will focus on for your physical examination of this patient.

Physical exam systems

Constitutional
Eyes
ENMT (Ears, Nose, Mouth, Throat)
Neck
Respiratory
Cardiovascular
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric

Key Systems

The following PE systems are recommended as your priority for this patient.

Constitutional
Respiratory
Cardiovascular
Gastrointestinal
Neurologic

Physical Exam Review

It is now time to document your findings in the cardiology SOAP note provided in your assignment instructions.

Past History

Initial Test Results

Your initial test results are available.

Chest X-ray preliminary interpretation: Lungs are well inflated and clear, cardio mediastinal silhouette is normal, no pleural effusion.

CBC:

WBC: 11, 000 cells / uL

Hgb: 11.8 g/dL

Hct: 35%

Platelets: 200,000 cells / uL

MCV: 70 fL

MCHC 28 g/dL

BMP:

Glucose: 200 mg/dL

BUN: 20 mg/dL

Creatinine: 0.92 mg/dL

Sodium: 138 mmol/L

Potassium: 4.3 mmol/L

Chloride: 98 mmol/L

CO2: 26 mmol/L

Calcium: 9.7 mmol/L

It is now time to document your findings in the cardiology SOAP note provided in your assignment instructions.

Final Reminder

The acute evaluation and management of a patient with chest pain can be rapid and overwhelming. Remember to ask someone on your team to contact the patient’s family and advise them of the change in the patient’s clinical status and verify if the chart has any indication of advanced directives on file.

It is now time to document your findings in the cardiology SOAP note provided in your assignment instructions.

You have reached the end of this activity.