Description
A 15-year-old immigrant was brought to the clinic by her mother because client complains of shortness of breath, chest pains, diaphoresis and easy fatiguability. She claims she has had on and off bouts of tonsillitis since she was a child that resulted in tonsillectomy surgery when she was 12. Last week, she was unable to participate in the cheer leading tryouts because of knee pain and a rash that she noticed on her trunk for the past 2 weeks. Body System – Cardiovascular I believe it is Rheumatic Fever. Please use template to fill out.
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Physical Assessment
Case Study Template
Name:
Week of Class (1-8):
Body System focus area (i.e., cardiovascular):
Case Study:
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
General survey
HEENT (head, eyes, ears,
nose, throat/thyroid)
Cardiovascular
Peripheral Vascular
Include
✓ (yes) or
– (not
indicated)
✓
✓
Notes
Auscultate heart sounds (stethoscope to
actual skin)
Breasts
Lymphatic
Pulmonary
✓
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 the last 5 years, scholarly, include clinical practice guidelines if available)
APA Format please, at least one reference
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