Description
Use the Case Study Template to complete.Be sure to include at least one reference.Include in-text citations as needed.Case StudyAn 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. please use the template attached to complete the assignment
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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 cita ons as needed (author, year).
Ques ons (if data is unavailable, indicate !unavailable”):
1. What is the client’s chief complaint?
2. What ques ons would you ask the client?
o
HPI (history of present illness)
o
ROS (review of systems)
o
Medical/Surgical/Psych History
o
Family History
o
Other
3. What physical examina ons would you include?
Body System
Include?
Notes
” (yes) or – (not indicated)
General survey
”
HEENT (head, eyes, ears, nose,
throat/thyroid)
Cardiovascular
Peripheral Vascular
ti
ti
ti
ti
Breasts
”
Auscultate heart sounds
(stethoscope to actual skin)
Lympha c
Pulmonary
”
Auscultate lung sounds (stethoscope to actual skin) – anterior
and posterior
Gastrointes nal/Abdominal
Genitourinary/Pregnancy
Integumentary
Musculoskeletal
Neurological
4.
4. What are per nent posi ve physical assessment ndings?
5. What are the per nent nega ve physical assessment ndings?
6. What are at least 3 di eren al diagnoses (use Up-to-Date App if needed)?
o
o
o
7. What is your primary diagnosis?
Pharmacotherapy (including complementary and alterna ve therapies)
o
Health promo on (preventa ve care, an cipatory guidance)
ti
o
fi
Client educa on (including lifestyle modi ca ons, if applicable)
fi
o
ti
Labs
fi
o
ti
Diagnos c procedures
ti
o
ti
ti
ti
ff
ti
ti
ti
ti
ti
ti
ti
8. What is your treatment plan?
o
Follow-Up
References
(within last 5 years, scholarly, include clinical prac ce guidelines if available)
ti
APA format please, at least one reference
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