Pertinent Positive Physical Assessment Findings Assignment

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Pertinent Positive Physical Assessment Findings Assignment

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?

 

  1. What questions would you ask the client?

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

 

  1. What physical examinations would you include? Pertinent Positive Physical Assessment Findings Assignment
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 Pertinent Positive Physical Assessment Findings Assignment    

 

  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

 

 

References

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

APA format please, at least one reference Pertinent Positive Physical Assessment Findings Assignment