MSN 560 Week 3 Case Study (Physical Assessment)
Body System focus area (i.e., cardiovascular): _pulmonary_
Case Study: Case 3: A 38-year-old artist has smoked since she was 18 years old.
She has noticed a mild, occasionally productive cough for the past few months. On
a recent trip to the mountains, she developed shortness of breath that caused her
to be nauseated. She has had no fever or chills. Her medical history includes
hypertension for which she is using lisinopril, metoprolol, and
hydrochlorothiazide.
Note: Include in-text citations as needed (author, year).
Questions (if data is unavailable, indicate “unavailable”):
1. What is the client’s chief complaint? Client’s CC is a mild, occasionally
productive couch for the past few months.
2. What questions would you ask the client?
o HPI (history of present illness): Please describe how your symptoms
started? Did your symptoms progress rapidly or gradually within the
past few months? Have you noticed any pain when you cough? If so,
can you describe the pain – is it intermittent, radiating, throbbing
(OPQRST)? On a scale of 1-10, what would you score your pain? Have
you noticed any discoloration with the phlegm/sputum when you
cough? If so, can you describe the color? Other than your recent trip
to the mountains, has there been other occasions where you have
felt short of breath? If so, can you describe what you were doing
when you felt short of breath? Do you get short of breath after
walking, doing an errand or doing daily activities of life? Have you
noticed if you are needing to use chest and neck muscles (accessory
muscles) more to help you breath better (U.S. Department of Health
, and Human Services, n.d.)? Other than the coughing, have you
noticed any chest tightness or wheezing throughout the day?
o ROS (review of systems): Have you noticed increase in fatigue or how
often you feel tired? Have you noticed any recent unintentional
weight loss? Have you noticed any discoloration in your lips or nails –
specifically blue? Have you noticed any curving and/or widening of
your nails? Have you noticed any swelling in your legs or ankles? If so,
how long ago did the swelling start? Have you noticed any chest
expansion (barrel chest) (World Health Organization, 2026). Have you
noticed any changes in your menstrual cycle, if so, can you describe
the changes? Have there been any changes in your bowel
movement?
o Medical/Surgical/Psych History: Do you have any past medical or
surgical history? Have you been hospitalized recently or within the
last year? If so, can you explain what the hospitalization was for?
Have you suffered from bronchitis or pneumonia? Do you get
frequent infections? Do you have any history of mental illness? Have
you had any recent thoughts of harming yourself or others? How
many days in the last week have you felt sad or unmotivated? When
was your last gynecological exam?
o Family History: Do you have any family history of cancer, specifically
lung cancer? Do you have family members who smoke? Do you have
any family history of COPD? Do you have a family history of mental
illness?
o Other: What do you do for work? Can you tell me how much you
smoke in a day? Other than smoking, are there any occupational or
environmental irritants you have been exposed to? Do you drink, if
so, how many beverages a week? Do you use any recreational drugs,
if so, what type and how often? Is there anything else you would like
to share with me that you might think might better help me diagnose
your symptoms? Pulmonary referral will also be needed.
3. What physical examinations would you include?
Body System focus area (i.e., cardiovascular): _pulmonary_
Case Study: Case 3: A 38-year-old artist has smoked since she was 18 years old.
She has noticed a mild, occasionally productive cough for the past few months. On
a recent trip to the mountains, she developed shortness of breath that caused her
to be nauseated. She has had no fever or chills. Her medical history includes
hypertension for which she is using lisinopril, metoprolol, and
hydrochlorothiazide.
Note: Include in-text citations as needed (author, year).
Questions (if data is unavailable, indicate “unavailable”):
1. What is the client’s chief complaint? Client’s CC is a mild, occasionally
productive couch for the past few months.
2. What questions would you ask the client?
o HPI (history of present illness): Please describe how your symptoms
started? Did your symptoms progress rapidly or gradually within the
past few months? Have you noticed any pain when you cough? If so,
can you describe the pain – is it intermittent, radiating, throbbing
(OPQRST)? On a scale of 1-10, what would you score your pain? Have
you noticed any discoloration with the phlegm/sputum when you
cough? If so, can you describe the color? Other than your recent trip
to the mountains, has there been other occasions where you have
felt short of breath? If so, can you describe what you were doing
when you felt short of breath? Do you get short of breath after
walking, doing an errand or doing daily activities of life? Have you
noticed if you are needing to use chest and neck muscles (accessory
muscles) more to help you breath better (U.S. Department of Health
, and Human Services, n.d.)? Other than the coughing, have you
noticed any chest tightness or wheezing throughout the day?
o ROS (review of systems): Have you noticed increase in fatigue or how
often you feel tired? Have you noticed any recent unintentional
weight loss? Have you noticed any discoloration in your lips or nails –
specifically blue? Have you noticed any curving and/or widening of
your nails? Have you noticed any swelling in your legs or ankles? If so,
how long ago did the swelling start? Have you noticed any chest
expansion (barrel chest) (World Health Organization, 2026). Have you
noticed any changes in your menstrual cycle, if so, can you describe
the changes? Have there been any changes in your bowel
movement?
o Medical/Surgical/Psych History: Do you have any past medical or
surgical history? Have you been hospitalized recently or within the
last year? If so, can you explain what the hospitalization was for?
Have you suffered from bronchitis or pneumonia? Do you get
frequent infections? Do you have any history of mental illness? Have
you had any recent thoughts of harming yourself or others? How
many days in the last week have you felt sad or unmotivated? When
was your last gynecological exam?
o Family History: Do you have any family history of cancer, specifically
lung cancer? Do you have family members who smoke? Do you have
any family history of COPD? Do you have a family history of mental
illness?
o Other: What do you do for work? Can you tell me how much you
smoke in a day? Other than smoking, are there any occupational or
environmental irritants you have been exposed to? Do you drink, if
so, how many beverages a week? Do you use any recreational drugs,
if so, what type and how often? Is there anything else you would like
to share with me that you might think might better help me diagnose
your symptoms? Pulmonary referral will also be needed.
3. What physical examinations would you include?
