Physical Assessment Case Study
Name: ________________________________________
Week of Class (1-8): ______
Body System focus area (i.e., cardiovascular): _____________________________
CASE: A 29-year-old newly immigrated woman complains of weakness, shortness of breath, cough and night sweats for the past month.
Case Study: (copy/paste here please)
Note: Include in-text citations as needed (author, year).
Questions (if data is unavailable, indicate “unavailable”):
What is the client’s chief complaint?
What questions would you ask the client?
Physical Assessment Case Study
HPI (history of present illness)
ROS (review of systems)
Medical/Surgical/Psych History
Family History
Other
What physical examinations would you include?
| Body System | Include?
ü (yes) or – (not indicated) |
Notes |
| General survey | ü | |
| HEENT (head, eyes, ears, nose, throat/thyroid) | ||
| Cardiovascular | ü | Auscultate heart sounds (stethoscope to actual skin) |
| Peripheral Vascular | ||
| Breasts | ||
| Lymphatic | ||
| Pulmonary | ü | Auscultate lung sounds (stethoscope to actual skin) – anterior and posterior |
| Gastrointestinal/Abdominal | ||
| Genitourinary/Pregnancy | ||
| Integumentary | ||
| Musculoskeletal | ||
| Neurological |
Physical Assessment Case Study
What are pertinent positive physical assessment findings?
What are the pertinent negative physical assessment findings?
What are at least 3 differential diagnoses (use Up-to-Date App if needed)?
What is your primary diagnosis?
What is your treatment plan?
Diagnostic procedures
Labs
Client education (including lifestyle modifications, if applicable)
Pharmacotherapy (including complementary and alternative therapies)
Health promotion (preventative care, anticipatory guidance)
Follow-Up
References
(within last 5 years, scholarly, include clinical practice guidelines if available)
APA format please, at least one reference
Physical Assessment Case Study
Diagnostic procedures
Labs
Client education (including lifestyle modifications, if applicable)
Pharmacotherapy (including complementary and alternative therapies)
Health promotion (preventative care, anticipatory guidance)
Follow-Up
References
(within last 5 years, scholarly, include clinical practice guidelines if available)
APA format please, at least one reference
Physical Assessment Case Study
Diagnostic procedures
Labs
Client education (including lifestyle modifications, if applicable)
Pharmacotherapy (including complementary and alternative therapies)
Health promotion (preventative care, anticipatory guidance)
Follow-Up
References
(within last 5 years, scholarly, include clinical practice guidelines if available)
APA format please, at least one reference