Case Study

SOUTHEASTERN COMMUNITY COLLEGE

RESPIRATORY THERAPY PROGRAM

PATIENT CASE STUDY

STUDENT NAME: ___________________ FACILITY: ______________ DATE:_________

PATIENT INITIALS: _______ DATE OF BIRTH: _____________ SEX:___________

CODE STATUS: _______ ADMISSION DATE: _________ CHIEF COMPLAINT:___________

Admission diagnosis: ____________________________________________________________

Past medical history: __________________________________________________________________________

ASSESSMENT OF PATIENT:

Heart rate: _____ Respiratory Rate:_____ Sao2:_____ Blood Pressure:__________

Breath sounds:_____________________________________________________________

Cough and sputum: __________________________________________________________

Color:________________ Neuro status:______________________________________

Chest inspection:___________________________ Extremities:__________________

Date and result of last chest x-ray________________________________________________

____________________________________________________________________________

How do the patient's physical findings relate to diagnosis?_____________________________________________________________________

______________________________________________________________________________

LAB VALUES:

Na+________ K+_______ Cl- ________ Hemoglobin & Hematocrit________________

WBC _____________ RBC_____________ Glucose ___________ BUN ___________

Creatinine _________ PT/PTT ____________________ Bilirubin____________

Blood or sputum culture results___________________________________________________

Relate any abnormal finding with patient's condition___________________________________

____________________________________________________________________________

RESPIRATORY CARE:

Oxygen device and setting: __________________________________________________________________________

Ventilator/IPPB/CPAP/BIPAP setting: __________________________________________________________________________

___________________________________________________________________________

Arterial blood gas result and interpretation:_________________________________________________________________

______________________________________________________________________________

Additional respiratory care orders: (Tx 's, CPT, etc)__________________________________________________________________________

______________________________________________________________________________

Indications for above therapies: ____________________________________________________________________________

______________________________________________________________________________

What are possible complications of above therapy?_____________________________________

______________________________________________________________________________

What changes in therapy would you suggest and why? __________________________________

______________________________________________________________________________

MEDICATIONS:

List patient's current medications: ___________________________________________________

______________________________________________________________________________

_____________________________________________________________________________

What are the indications for these medications? ____________________________________________________________________________

_____________________________________________________________________________

PATIENT COURSE

Summarize the patient's hospital course up to this time: ______________________________________________________________________________

______________________________________________________________________________

What is the patient's prognosis? Support your conclusion. _____________________________________________________________________________

_____________________________________________________________________________