Case Study Guide

Information That Should Always Be Included:

Vital Signs

When discussing the patient’s vital signs (both at admission and throughout the hospitalisation), you must include the following:

  • Temperature
  • Pulse and/or heart rate
  • Respiration rate
  • Level of consciousness
  • Mucous membranes
  • Capillary refill time
  • Hydration

Each time you discuss these parameters you will need to include the normal reference ranges, and how your patient’s results compared. You will need to discuss how abnormal results were either justified or attended to and reported. Information like this can be done as a template and copied and pasted into all your case studies and just adjust the information to suit the case. This will save you time.

Examples:

Normal range Patient data
HR 60-180 bpm 104 bpm
RR 10-30 bpm 28 bpm
Temp 38.3-38.7°C 39.5°C
CRT 1-2sec 1.5
MM Pink, moist Pink and moist
Level of Consciousness Bright and responsive BAR
Hydration Hydrated Hydrated

All the vital signs were in a normal range, but the patient was slightly warmer than normal.

Normal range Patient data
HR 60-180 bpm 104 bpm
RR 10-30 bpm 28 bpm
Temp 38.3-38.7°C 39.5°C
CRT 1-2sec 1.5
MM Pink, moist Pink and moist
Level of Consciousness Bright and responsive BAR
Hydration Hydrated Hydrated

All vital signs were in the normal ranges, except the patient was mildly hyperthermic.

Normal range Patient data
HR 60-180 bpm 104 bpm
RR 10-30 bpm 28 bpm
Temp 38.3-38.7°C 39.5°C
CRT 1-2sec 1.5
MM Pink, moist Pink and moist
Level of Consciousness Bright and responsive BAR
Hydration Hydrated Hydrated

All vital signs were in the normal ranges, except the patient was mildly hyperthermic. The raised temperature could be due an infectious inflammatory process or even the demeanour of the patient, as they were hyperexcited.

In addition to recording the vital signs, the first time you mention the recording of these vital signs you will also need to discuss how you performed this assessment, what equipment you used, how the patient was restrained and discuss any OHS considerations that may be present.

Thoracic auscultation was performed with a stethoscope, and the patient’s heart and lung sounds were assessed. With the patient standing on all four legs, the stethoscope was placed on the patient’s chest just caudal to the point where the dogs left elbow meets the chest. The heart beats were counted for 15 seconds and then multiplied by 4 to get the heart rate per minute. It is ideal to use an assistant to restrain the patient when performing a physical examination to ensure the risk of getting bitten or scratched is reduced.

Don’t forget to discuss any developing patterns in the patient’s condition as it changes over time.

Over the past 24 hours, it was noted that the patient’s temperature rose by 0.7°C. This was most likely due to the infection the patient had.