Case 2: A 29-year-old newly immigrated woman complains of weakness, shortness of breath, cough and night sweats for the past month.
Physical Assessment
Case Study Template
Name: ________________________________________
Week of Class (1-8): ______
Body System focus area (i.e., cardiovascular): _____________________________
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?
- 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 |
- 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
Case 2: A 29-year-old newly immigrated woman complains of weakness, shortness of breath, cough and night sweats for the past month.
Physical Assessment
Case Study Template
Name: ________________________________________
Week of Class (1-8): ______
Body System focus area (i.e., cardiovascular): _____________________________
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?
- 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 |
- 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