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 HPI (history of present illness)
o ROS (review of systems)
o Medical/Surgical/Psych History
o Family History
o Other
3. What physical examinations would you include?
|
Body System |
Include? ü (yes) |
Notes |
|
General survey |
ü |
|
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HEENT (head, eyes, ears, nose, throat/thyroid) |
|
|
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Cardiovascular |
ü |
Auscultate heart sounds (stethoscope to actual skin) |
|
Peripheral Vascular |
|
|
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Breasts |
|
|
|
Lymphatic |
|
|
|
Pulmonary |
ü |
Auscultate lung sounds (stethoscope to actual skin) – anterior and |
|
Gastrointestinal/Abdominal |
|
|
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Genitourinary/Pregnancy |
|
|
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Integumentary |
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|
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Musculoskeletal |
|
|
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Neurological |
|
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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 Diagnostic procedures
o Labs
o Client education (including lifestyle modifications, if applicable)
o Pharmacotherapy (including complementary and alternative therapies)
o Health promotion (preventative care, anticipatory guidance)
o Follow-Up
References
(within last 5 years, scholarly, include clinical practice guidelines if available)
APA format please, at least one reference