Case 1: An 89-year-old female complains of a ‘stabbing chest pain’ and points to the area just below her scapula at the right mid-clavicular line. She states that she had an up
Case 1: An 89-year-old female complains of a "stabbing chest pain" and points to the area just below her scapula at the right mid-clavicular line. She states that she had an upper respiratory infection last week that "just seems to hang on." No other complaints.
- Use the Case Study Template to complete Download Use the Case Study Template to complete
- Be sure to include at least one reference.
- Include in-text citations as needed.
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”):
1. What is the client’s chief complaint?
2. What questions would you ask the client?
· HPI (history of present illness)
· ROS (review of systems)
· Medical/Surgical/Psych History
· Family History
· Other
3. 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 |
4. What are pertinent positive physical assessment findings?
5. What are the pertinent negative physical assessment findings?
6. What are at least 3 differential diagnoses (use Up-to-Date App if needed)?
·
·
·
7. What is your primary diagnosis?
8. 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
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