Instructions:
Use the Case Study Template to complete.
Discuss the case study below
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 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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Formatting
Title Page
Citation
Outline
