Week 3 Case Study: Respiratory
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?9-year-old?female presents with her mother complaining of a dry cough that wakes up everyone in the house each night for the last two weeks.?
Case 2:?A?29-year-old?newly immigrated woman complains of weakness, shortness of breath,?cough?and night sweats for the past month.
Case 3: A 38-year-old artist has smoked since she was 18 years old. She has noticed a mild, occasionally productive cough for the past few months. On a recent trip to the mountains, she developed shortness of breath that caused her to be nauseated. She has had no fever or chills. Her medical history includes hypertension for which she is using lisinopril, metoprolol, and hydrochlorothiazide.
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 clients 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
