Case study: respiratory
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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”):
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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