Description
Week 1 Case Study: Fundamentals
Start Assignment
Due Sunday by 11:59pm
Points 25
Submitting a file upload
Instructions:
Use the Case Study Template to complete. Download Use the Case Study Template to complete.
Be sure to include at least one reference.
Include in-text citations as needed.
Select one case to discuss.
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 18-year-old daughter, and has been attempting to have another child with her new partner. She has been unsuccessful.
Case 2: A 47-year-old female complains of with severe right shoulder/ neck pain x 3 months. She denies any injury or known precipitating event. The pain seems to be worse with motion. Most of the pain is in the lateral arm/neck area. The arm pain stops in the middle of the arm. The client denies paresthesia in the hands. During the exam, she has lots of pain and full passive/active motion of the shoulder/neck.
Case 3: A 42-year-old male complains of painless swelling on the left side of his neck x 30 days. History: controlled diabetes mellitus and hypertension. He has had a slight fever and generalized body ache x 15 days. He has recently developed foul-smelling diarrhea, approximately 8 episodes per day with a 4 kg weight loss in 15 days. Diet: vegetarian. Allergies: none. Upon physical examination, + neck welling (posterior triangle of the left side of the neck), non-tender, not matted.
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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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