Instructions:
Select one case to discuss.
Physical Assessment
Case Study Template
Name: Jessenia Alegria
Week of Class (1-8): 1
Body System focus area (i.e., cardiovascular): ENDOCRINE SYSTEM AND REPRODUCTIVE SYSTEM
Case Study: Case 1: 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 18year-old daughter, and has been attempting to have another child with her new partner. She has been
unsuccessful.
Questions (if data is unavailable, indicate “unavailable”):
1. What is the client’s chief complaint?
The client’s chief complaint is progressive weight gain, fatigue, postural dizziness, memory loss,
slow speech, deepening voice, dry skin, constipation, cold intolerance, and irregular menstrual
cycles. She has been unsuccessful in conceiving another child.
2. What questions would you ask the client?
History of Present Illness (HPI):
Can you describe in more detail your weight gain? How much weight have you gained,
and over what time?
How would you describe your fatigue? Is it constant or intermittent? Does it affect your
daily activities?
Can you explain the postural dizziness you’re experiencing? When does it occur, and
how long does it last?
Tell me more about your memory loss. Are you having difficulty remembering recent
events or experiencing other memory problems?
How has your speech changed? Do you feel it is slower, or have you noticed difficulty
speaking clearly?
Can you elaborate on the changes in your voice? How long have you noticed this
deepening of your voice?
Describe the condition of your skin. Is it consistently dry? Have you noticed any rashes
or other skin abnormalities?
Tell me about your bowel movements. Are you experiencing difficulty passing stools or a
decrease in frequency?
How do you tolerate cold temperatures? Have you noticed a change in your ability to
tolerate cold environments?
Review of Systems (ROS):
Have you noticed any changes in your appetite or eating habits?
Do you have any problems with excessive thirst or increased urination?
Are you experiencing any joint pain or stiffness?
Have you noticed any changes in your menstrual cycles, such as the length or heaviness
of your periods?
Do you have any issues with sleep, such as difficulty falling or staying asleep?
Have you experienced any mood changes, anxiety, or depression symptoms recently?
Medical/Surgical/Psych History:
Do you have any known medical conditions or chronic illnesses?
Have you undergone any surgeries in the past? If yes, please provide details.
Have you ever been diagnosed with any mental health disorders? If yes, please specify.
Family History:
Are there any significant medical conditions or illnesses that run in your family?
Other:
Are you currently taking any medications or supplements?
Have you made any recent lifestyle changes, such as diet or exercise habits?
3. What physical examinations would you include?
Body System
Include?
✓ (yes) or – (not indicated)
Notes
•
General survey
✓
•
HEENT (head, eyes, ears, nose,
throat/thyroid)
✓
•
•
•
Cardiovascular
✓
Peripheral Vascular
Breasts
Lymphatic
•
Observe the client’s overall
appearance, noting any
signs of distress or
discomfort.
Inspect the face and skin for
any abnormalities.
Assess the thyroid gland for
enlargement or nodules.
Evaluate the voice for any
abnormalities.
Measure blood pressure
and assess for any
irregularities.
Auscultate heart sounds for
any murmurs or abnormal
rhythms.
Pulmonary
Gastrointestinal/Abdominal
•
✓
•
Genitourinary/Pregnancy
✓
Integumentary
•
✓
Musculoskeletal
Neurological
•
•
•
✓
Inspect the abdomen for
any distention, scars, or
masses.
Palpate the abdomen for
tenderness or organ
enlargement.
Inquire about any
genitourinary symptoms or
changes in urinary patterns.
Discuss the client’s
attempts to conceive and
any difficulties experienced.
Inspect the skin for dryness,
pallor, or abnormal lesions.
Assess the client’s level of
consciousness, orientation,
and cognition.
4. What are pertinent positive physical assessment findings?
▪ Weight gain of 20 pounds over the last year.
▪ Fatigue.
▪ Postural dizziness.
▪ Loss of memory.
▪ Slow speech.
▪ Deepening of voice.
▪ Dry skin.
▪ Constipation.
▪ Cold intolerance.
▪ Irregular menstrual cycles.
▪ Difficulty conceiving.
5. What are the pertinent negative physical assessment findings?
▪ No abnormal skin findings apart from dryness.
▪ No abnormalities in the head, eyes, ears, nose, throat, or thyroid.
▪ No abnormalities in the cardiovascular system (e.g., murmurs, irregular rhythms).
▪ No abnormal peripheral vascular findings.
▪ No breast lumps or abnormalities were detected.
▪ No palpable lymph node enlargement or tenderness.
▪ No abnormal lung sounds were detected.
▪ No abnormal abdominal findings (e.g., distention, masses, tenderness).
▪ No genitourinary symptoms were reported apart from irregular menstrual cycles
and difficulty conceiving.
▪ No abnormalities in the integumentary system (e.g., lesions, pallor).
▪
▪
No musculoskeletal abnormalities were detected.
No neurological abnormalities were detected apart from potential cognitive changes
associated with memory loss and slow speech.
6. What are at least 3 differential diagnoses (use Up-to-Date App if needed)?
o
o
o
Hypothyroidism: The symptoms of weight gain, fatigue, constipation, dry skin, cold
intolerance, irregular menstrual cycles, and potential voice changes (deepening of voice)
could indicate an underactive thyroid gland (Chiovato et al., 2019). Further thyroid
function and hormone levels evaluation would be necessary to confirm this diagnosis.
Polycystic Ovary Syndrome (PCOS): The combination of weight gain, irregular menstrual
cycles, difficulty conceiving, and potential hormonal imbalances suggests the possibility
of PCOS (Cena et al., 2020). This condition is characterized by the presence of multiple
ovarian cysts, hormonal disturbances, and reproductive issues. Additional diagnostic
tests, such as hormonal analysis and ultrasound imaging, may be required to support
this diagnosis.
Adrenal insufficiency: Adrenal insufficiency, specifically primary adrenal insufficiency
(Addison’s disease), could be considered due to symptoms such as fatigue, postural
dizziness, loss of memory, and potential skin changes. Other associated symptoms of
adrenal insufficiency, such as electrolyte imbalances and hyperpigmentation, should
also be evaluated.
7. What is your primary diagnosis?
Based on the symptoms and findings mentioned in the case study, the primary diagnosis is likely
to be hypothyroidism. Notably. Hypothyroidism is a condition characterized by an underactive
thyroid gland, which leads to a decrease in the production of thyroid hormones. The symptoms
of weight gain, fatigue, constipation, dry skin, cold intolerance, irregular menstrual cycles, and
potential voice changes align with the typical presentation of hypothyroidism. Confirmatory
diagnostic tests, such as thyroid function tests (TSH, T4 levels), would be necessary to support
the diagnosis (Andersen et al., 2022).
8. What is your treatment plan?
o
o
Diagnostic procedures:
▪ Thyroid function tests: Perform blood tests to measure levels of thyroid-stimulating
hormone (TSH) and thyroid hormones (such as T4 and T3) to confirm the diagnosis
and assess the severity of hypothyroidism.
Labs:
▪
o
o
o
o
Complete blood count (CBC): Evaluate for any associated anemia or other blood
abnormalities.
▪ Lipid profile: Assess lipid levels, as hypothyroidism can affect lipid metabolism
(Gluvic et al., 2020).
▪ Additional tests: Depending on the clinical presentation and suspected underlying
causes, further tests such as antithyroid antibodies (to check for autoimmune
thyroid disease) or imaging studies (e.g., thyroid ultrasound) may be ordered.
Client education and lifestyle modifications:
▪ Medication adherence: Educate the client about the importance of taking thyroid
hormone replacement medication (e.g., levothyroxine) as prescribed and at the
same time each day.
▪ Diet: Encourage a balanced diet with a focus on foods rich in iodine, selenium, and
zinc to support thyroid function.
▪ Exercise: Discuss the benefits of regular exercise in maintaining overall health and
managing weight.
▪ Stress management: Emphasize stress reduction techniques as stress can impact
thyroid function.
Pharmacotherapy:
▪ Thyroid hormone replacement therapy: Prescribe levothyroxine, a synthetic form of
the thyroid hormone, to supplement the deficient thyroid hormone levels (Jonklaas,
2022). Adjust the dosage based on the patient’s specific needs and regular
monitoring of thyroid function tests.
Complementary and alternative therapies:
▪ Discuss the use of complementary therapies such as acupuncture, herbal
supplements, or mind-body techniques with the client, considering their
preferences. However, emphasize that these should not replace conventional
medical treatment but should be used with appropriate medical management.
Health promotion and preventative care:
▪ Regular follow-up appointments: Schedule follow-up visits to monitor the
effectiveness of the treatment and make any necessary adjustments to medication
dosage.
▪ Periodic thyroid function tests: Regularly monitor thyroid hormone levels to ensure
optimal hypothyroidism management.
▪ Health maintenance: Guide on maintaining a healthy lifestyle, including regular
exercise, stress management, and routine health screenings.
References
Andersen, S., Karmisholt, J., Bruun, N. H., Riis, J., Noahsen, P., Westergaard, L., & Andersen, S. L. (2022).
Interpretation of TSH and T4 for diagnosing minor alterations in thyroid function: a comparative
analysis of two separate longitudinal cohorts. Thyroid research, 15(1), 19.
https://doi.org/10.1186/s13044-022-00137-1
Cena, H., Chiovato, L., & Nappi, R. E. (2020). Obesity, Polycystic Ovary Syndrome, and Infertility: A New
Avenue for GLP-1 Receptor Agonists. The Journal of clinical endocrinology and metabolism,
105(8), e2695–e2709. https://doi.org/10.1210/clinem/dgaa285
Chiovato, L., Magri, F., & Carlé, A. (2019). Hypothyroidism in Context: Where We’ve Been and Where
We’re Going. Advances in therapy, 36(Suppl 2), 47–58. https://doi.org/10.1007/s12325-01901080-8
Gluvic, Z. M., Obradovic, M. M., Sudar-Milovanovic, E. M., Zafirovic, S. S., Radak, D. J., Essack, M. M.,
Bajic, V. B., Takashi, G., & Isenovic, E. R. (2020). Regulation of nitric oxide production in
hypothyroidism. Biomedicine & pharmacotherapy = Biomedecine & pharmacotherapie, 124,
109881. https://doi.org/10.1016/j.biopha.2020.109881
Jonklaas J. (2022). Optimal Thyroid Hormone Replacement. Endocrine reviews, 43(2), 366–404.
https://doi.org/10.1210/endrev/bnab031
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?
o
o
o
o
o
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
Include?
✓ (yes) or – (not indicated)
✓
✓
Auscultate heart sounds
(stethoscope to actual skin)
✓
Auscultate lung sounds
(stethoscope to actual skin) –
anterior and posterior
Peripheral Vascular
Breasts
Lymphatic
Pulmonary
Gastrointestinal/Abdominal
Genitourinary/Pregnancy
Integumentary
Notes
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)?
o
o
o
7. What is your primary diagnosis?
8. What is your treatment plan?
o
o
o
o
o
o
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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