Regional Write-up & Case Study “Edward”

Purpose:  To give students opportunity to use Critical thinking and Clinical Judgement and document their finding using the Reginal Write-up and the SOAP note format.

Directions:

1. Assess your lab partner and document findings (subjective and objective) using Regional Write-up lists on pgs. 175 and 187 from Jarvis workbook.

2. Read the Case Study “Edward” carefully.
3. Answer 5 Case Study questions. This is to help you link theory to practice.
4. Submit to Canvas for grading.

Grading Rubric

	Content	Points Possible	Earned Points
	Regional Write-ups – Heart (pg. 175) and Peripheral Vascular (pg. 187) in Jarvis workbook Data Complete (subjective and objective)Used correct terminology	10
	Highlight relevant subjective information in yellow and objective information in green. All relevant information highlighted	4
	Write out a symptom analysis for Edwards’s present illness. Choose one of the following mnemonics: PQRSTU, OLD CARTS or COLD SPA). Please label the mnemonic. Data CompleteAddressed all issuesLabeled mnemonic.	2
	Are you missing any information? What further subjective questions would you want to ask Edward? (Name at least 4 questions with rationales). Addressed main concernsIncluded correct number of questions and included rationales	4
	Review the subjective and objective data and then cluster the patient data. What do you think is going on with Edward and why? Includes all relevant subjective and objective informationUses clinical judgement	1
	Write a SOAP note using Subjective and Objective information only to summarize the key health history and physical assessment findings. Data Complete / Included all relevant information (Subjective and Objective)Information clear, organized and documented in the correct system.	4
	Total points possible	25

Case Study “Edward”

I.  Health History:

Reason for visit: “I have pain in my chest and arm.”

Client Profile: Edward is a 55-year-old male who is a chief executive officer of the local bank. He comes to the emergency department with complaints of chest pains that began about 1 hour ago. He describes the pain as pressure under the sternum that radiates into his left arm and up into his jaw.  On a scale of 1 to 10, he rates his pain intensity as a 7/10. He feels short of breath and is slightly nauseated.

He has had similar symptoms a couple of times over the previous two weeks, but the episodes only lasted for 5 to 10 minutes and then went away when he sat down and rested. He noticed that the pain with those episodes started when he was climbing stairs but went away when he sat down and rested.

The nurse gave Edward a sublingual nitroglycerin in the triage area which helped to ease his pain. Edward denies palpitation, blurred vision, emesis, or leg pain with walking. He has had hypertension for 25 years and gastroesophageal reflux disease (GERD) for 15 years. Edward takes medications for his blood pressure but can’t remember what their names are.

Edward has no known allergies and smokes a pack of cigarettes daily since the age of 15. He is a social drinker who denies recreation drug use. His family history reveals that his father died of an acute myocardial infarction at the age of 50. His mother has hypertension and is still living. His grandfather died at age 45 from a presumed acute myocardial infarction.  Edward is currently separated from his wife.

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II. Physical Assessment:

Edward’s Vital signs are: T- 98.7; Pulse- 83, regular, 2+; RR- 28, non- labored; BP- 160 /100 in both arms; Oxygen Saturation 92 on Room Air. Edward is an alert obese middle- aged man, who is pale and diaphoretic with rapid, shallow breathing. He has no rashes; nails are smooth, and no clubbing or cyanosis is noted. His head is round, smooth with no trauma noted. His sclera is white, and conjunctivae is clear, his pupils constrict from 3mm to 2mm and are equal, round, reactive to light and accommodate. Fundi with sharp discs, no hemorrhages noted but he does have arteriovenous nicking present. Neck is supple with trachea midline. S1 and S2 sound heard on auscultation. Right JVD distended. No extra sounds or murmur heard. Pulse in Dorsalis pedis (DP) and posterior tibial (PT) are 2+ and symmetrical. Lungs are clear in all lobes bilaterally, no adventitious sound heard, symmetrical chest rise. Abdomen is rounded and non-tender with bowel sounds heard in all 4 quadrants. His hand grip is strong bilaterally and dorsal flexion and planter flexion are both strong bilaterally as well.  He is urinating independently with no difficulty.

Please answer the following Case Study questions:

1. Highlight relevant subjective information in yellow and objective information in green.

2. Write out a symptom analysis for Edward’s present illness. Choose one of the following mnemonics: PQRSTU, OLD CARTS or COLD SPA. Please label mnemonic.

• Are you missing any information? What further subjective questions would you want to ask Edward? (Name at least 4 questions with rationales)

4. Review the subjective and objective data and then cluster the data. Present the relevant data.  What do you think is going on with Edward and why?

• Write a SOAP note using Subjective and Objective information only to summarize the key health history and physical assessment findings.

Use the format below:

S	Health History
	Biographical data
	Reason for seeking care
	Present health or History of present Illness
	Past Medical History
	Allergies
	Last menstrual period
	Medications
	Family History
	Social history
	Nutritional Habits
O	Physical Exam
	Vital Signs
	General Survey
	Skin
	HEEN
	Thorax and Lungs
	Cardiovascular
	Abdomen
	Neurological
	Musculoskeletal
	GU