Case 1: An 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 up

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)?

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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