Case Study: Respiratory Assignment

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Case 2: A 29-year-old newly immigrated woman complains of weakness, shortness of breath, cough and night sweats for the past month.

Physical Assessment

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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”): Case Study: Respiratory Assignment

  1. What is the client’s chief complaint?

 

  1. What questions would you ask the client?

 

  • HPI (history of present illness)
  • ROS (review of systems)
  • Medical/Surgical/Psych History
  • Family History
  • Other

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  1. 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) Case Study: Respiratory Assignment
Peripheral Vascular    
Breasts    
Lymphatic    
Pulmonary ü Auscultate lung sounds (stethoscope to actual skin) – anterior and posterior
Gastrointestinal/Abdominal    
Genitourinary/Pregnancy    
Integumentary    
Musculoskeletal    
Neurological    

 

  1. What are pertinent positive physical assessment findings?

 

  1. What are the pertinent negative physical assessment findings?

 

  1. What are at least 3 differential diagnoses (use Up-to-Date App if needed)?

 

 

  1. What is your primary diagnosis?

 

  1. 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. Case Study: Respiratory Assignment

References

(within last 5 years, scholarly, include clinical practice guidelines if available)

APA format please, at least one reference