Sample Nursing Case Studies

Abdomen: Obtuse with minimal bowel sounds, slightly distended. There is RLQ (right lower quadrant) tenderness with guarding and with pinpoint rebound. Positive McBurney and obturator signs with a negative psoas sign.

PHYSICAL EXAMINATION: Vital Signs. TEMPERATURE: 101.0, Blood Pressure- 127/179, Heart Rate-129, Respirations- 185, Weight-215. Situations 96% on room air. Pain Scale- 8/10. HEENT-Normal cephalic, atrumatic pupils equally round and reactive to light. Extra ocular motions intact. ORAL: Shows oral pharynx clear but slightly dry mucosal membranes. TMS: Clear. NECK: Supple, No thrangegally or JVD. No cervical, subclavicular, axilarry or lingual lymphinalpathy.

PHYSICAL EXAMINATION: Vital signs are WNL. Apparently he has had no chills, night sweats, or favors. Generalized malaise and a lack of energy have been the main concerns. HEART: Regular rate and rhythm with S1 and S2. No S3 or S4 is heard at this time. LUNGS: Bilateral rhonchi. No significant amphoric sounds are noted. ABDOMON: Soft nontender. No hepatosplenomegaly or masses are detected. RECTAL EXAM: Prostate smooth and firm. No stool is present for hemoccult test.

Physical Examination: General: The patient is an alert, oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78 and pulse 68 and regular. Temperature is 38.56 oC (101.4 oF). HEENT:Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears are clear. Throat is normal. Neck: The neck is supple with no carotid bruits. Lungs: The lungs are clear to auscultation and percussion. Heart: Regular rate and rhythm. Abdomen:Bowel sounds are normal. There is rebound tenderness with maximal discomfort on palpation in the right lower quadrant. Extremities: No clubbing, cyanosis, or edema.

PAST MEDICAL/SURGICAL HISTORY: As above. SOCIAL HISTORY: Status post heavy smoking, 50+-pack-year history. He quit 10 years ago. Status post alcohol abuse, quit 3 or 4 years ago. He lives by himself and no longer drives but has 2 daughters here in Miami who take him where he needs to go. FAMILY HISTORY: Patient’s wife died 14 years ago of COPD due to lifelong smoking. Brother has diabetes mellitus. Unremarkable family history otherwise. REVIEW OF SYSTEMS: No fever, no nausea, no vomiting. Patient has incontinence of bowel. No shortness of breath, no chest pain, no palpitations. PHYSICAL EXAMINATION: Well-developed, well-nourished white male who is alert and oriented x3. Wears bilateral hearing aids. Afebrile with blood pressure 130/70. NECK: No carotid bruits. LUNGS: Clear to auscultation bilaterally. HEART: S1, S2 normal. No murmur. No S3 or S4. ABDOMEN: Soft, nontender. No arterial bruits. No masses, no organomegaly. EXTREMITIES: No edema. No pulses present in the lower extremities. The right great toe is absent. The left great toe shows a 2 x 1 cm deep ulcer with redness around the toe with pus extruding. PLAN 1. Get consult with Dr. Beth Brian, Infectious Disease. 2. Follow up with Dr. Hirsch, Orthopedics. (Continued)

On 10/13/16 I met Mr. Westover at the office of Dr. Raymond. Mr. Westover ambulates with a cane. He reports when he is at home he doesn’t use it. Physical therapy continues to work with strength and balance goals. Mr. Westover feels he would benefit with another month of therapy. He has completed speech therapy. The peg tube site on Mr. Westover’s abdomen still has a scab and scant drainage at times. Dr. Raymond would like his to keep putting Neosporin on it. If it doesn’t fully close doctor would like him to follow up with gastrologist who put the tube in. Mr. Westover examination shows weakness still on the left leg, and right arm.

Skin: The client’s skin is even in color, unblemished and no presence of any foul odor. She has a good skin turgor, and skin’s temperature is within normal limit. There is good oxygen, circulation, and nutrition with no tissue damage. Patient has concern about being lights skin, but no melanoma noted to skin. Palms, sole of the feet, and lips show no signs of cyanosis. No erythema or redness noted to skin.

Elijah “Poochie” Diaz 8/27/15 mouth mirror inspection; TEMP 101.4°F; PUL 78; RESP 14; BP 110/75; HHUD patient has tenderness in his neck; while preforming extra oral exam noticed swelling and warmth on the submandibular nodes; soft tissue hard tissue NSF_______dira4620

which was left in place. No oozing or active bleeding is evident at this time, and the

The patient is a 37-year-old African-American female Biochemist who works in quality control testing. She has been married since October 1, 1999 to her husband, her only sexual sexual partner. She has been an avid smoker since 1992 (1 pack a day) and stopped smoking briefly in 2004 during her pregnancy then continued smoking thereafter.

General Appearance: The patient is 36-year-old Caucasian woman who is in no apparent distress. Patient is alert and oriented to person, place, time and situation, cooperative, well-nourished, well-groomed, and dressed appropriately for the weather. Hygiene is excellent

This is 58 year old white female. She is complains of generalized body aches and pains for the past 2 to 3 days. Patient states her throat and ears are also hurting. Patient is a resident at the Jessie Place and her room mate has been sick. Patient reports some fever. Patient is a current tobacco user denies use of alcohol or illicit drugs. Denies chest pain, SOB, N/V/ D. Current pain

REASON FOR VISIT: Patient was brought in by mother and father after extended period of complaints regarding blurred vision and headaches. Physical activities result in some labored breathing. Patient is complaining of feeling generally lethargic. Tylenol has been effective in temporarily assisting with symptoms and discomfort. Initial blood pressure readings indicate higher than normal elevations. Also, complaints about "dizzy spells" and occasional feelings best described as vertigo.

“Sixth or seventh grade education; housewife and mother of five. Breathing difficult since childhood due to recurrent throat infections and deviated septum in patient’s nose. Physician recommended surgical repair. Patient declined. Patient had one toothache for nearly five years; tooth eventually extracted with several others. Only anxiety is oldest daughter who is epileptic and can’t talk. Happy household. Very occasional drinker. Has not traveled. Well nourished, cooperative. Patient was one of ten siblings. One died of car accident, one from rheumatic heart, and one was poisoned. Unexplained vaginal bleeding and blood in urine during last two pregnancies; Physician recommend

Examination: BAR, stressed reaction when restrained for vaccines, T: 100.1, P: 48, R: 20, BCS 4/9, pink moist mucous membranes, CRT<2 seconds, no auscultable cardiac or respiratory abnormalities, good gut sound in all four quadrants (1-2 borborygmi sounds per minute), no palpable digital pulse on any limbs, Hirsutism evident over abdomen, slightly pendulous abdomen