A 42-year-old female complains of progressive weight gain of 20 pounds over the last year, fatigue, postural dizziness, loss of memory, slow speech, deepening of her voice, dry skin, constipation, and cold intolerance. She claims her menses have been irregular x 1 year. She has an 18-year-old daughter, and has been attempting to have another child with her new partner. She has been unsuccessful.
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
