Physical Assessment

Physical Assessment

Case Study Template

Name: ________________________________________

Week of Class (1-8): ______

Body System focus area (i.e., cardiovascular): _____________________________

Case Study:

The woman, 29 years of age, who recently immigrated to the USA, has weakness, shortness of breath, and a cough.

What is the major complaint of the client?

The client has progressive weakness, dyspnea, and a chronic cough.

What are the questions that you would ask the client?

The nurse would ask questions to learn more about the client and their symptoms and the potential causes. These are the times the symptoms began, whether the cough is dry or productive, and whether the sputum contains any blood. The client ought to be questioned also on related symptoms like fever, night sweats, and weight loss. Other questions involve any recent contact with persons with tuberculosis, living environment, recent travel history, and past medical history with chronic diseases such as HIV. Social history, like smoking and alcohol consumption, should also be evaluated.

HPI (history of present illness)

The patient is a 29-year-old woman with a history of increasing weakness, dyspnea, and chronic cough for several weeks. The symptoms have progressively been getting worse and are impacting day-to-day activities. The cough can be productive and be accompanied by systemic symptoms like fatigue, which may or may not be accompanied by a fever and weight loss. The fact that the client is a new immigrant makes him susceptible to infectious diseases, including tuberculosis (Alhajjaj et al., 2024). No chest pain has been reported, but shortness of breath is reported, particularly during activity.

ROS (review of systems)

General: Denies weakness, fatigue, and potential weight loss.

Pulmonary: Denies any persistent cough or dyspnea.

Cardiovascular: No chest pain or palpitations.

Gastrointestinal: Denies potential lack of appetite.

Neurological: Denies lightheadedness or unconsciousness.

Integumentary: No skin changes reported.

Medical/Surgical/Psych History

The client has no medical history of chronic disease or past surgeries (data unavailable). No psychiatric history is reported, but there may be stress associated with new immigration.

Family History

None of the family history of chronic or hereditary diseases was reported (data unavailable).

Other

The client is a newcomer to the country, which can expose her to infectious diseases, including tuberculosis. The living conditions can be overcrowded. The history of smoking and alcohol needs to be evaluated (currently not available).

What physical examinations would you include?

Body System Include?

ü (yes) or – (not indicated)

 Notes
General survey ü Inspect general appearance, tiredness, loss of weight, and breathlessness.
HEENT (head, eyes, ears, nose, throat/thyroid)
✔

 
 

Examine signs of lymphadenopathy, pallor, and infection.
Cardiovascular ü Examine heart sounds (stethoscope to real skin), examine rate and rhythm.
Peripheral Vascular ü
Evaluate circulation, capillary refill, and peripheral pulses.

 
Breasts _ Not specified in the present condition.
Lymphatic ü Examine the presence of large lymph nodes.
Pulmonary ü Listen to lungs (stethoscope to actual skin) – anterior and posterior.
Gastrointestinal/Abdominal ü Determine nutrition and potential weight loss.
Genitourinary/Pregnancy _ Unless other symptoms occur.
Integumentary ü Examine the skin, pallor, and dehydration.
Musculoskeletal ü Determine muscle strength and overall weakness.
Neurological ü Test mental status and orientation.

 

What are the relevant good physical examination findings?

The positive findings, which are relevant, may include: crackles in the lung fields, increased breathing rate, fatigue, and loss of weight. It is also possible that the client will present with swollen lymph nodes and general weakness, which is also typical of a possible infectious respiratory disorder.

What are the pertinent negative physical assessment findings?

The appropriate negative findings include the absence of chest discomfort, absence of cyanosis, absence of peripheral edema, and absence of neurological defects. The findings help in the eradication of cardiovascular causes and severe systemic errors.

Name at least 3 differential diagnoses (see Up-to-Date App if necessary)?

  • Lung tuberculosis – the outcome of chronic cough and weakness, and another predisposing factor, which may include new immigration.
  • Pneumonia – caused by dyspnea and cough.
  • Chronic bronchitis – due to the chronic coughing and inhalation problems.

How do you make your final diagnosis?

This is primarily pulmonary tuberculosis. It is justified by the fact that the client has a chronic cough and is weak and at risk due to the recent immigration and possibly, in contact with the infectious environment.

What is your treatment plan?

Diagnostic procedures

A chest X-ray is required to determine the functions of the lungs. A Sputum test, like GeneXpert tests, should confirm it. Additional imaging, such as a CT scan, may be required.

Labs

Full blood count (CBC), erythrocyte sedimentation rate (ESR), and HIV test should be included in the laboratory test, as TB is frequently associated with immunocompromised diseases.

Education of the client (including lifestyle changes, where appropriate).

The client needs to be informed about the necessity of being strict on the medicine to cure completely and prevent resistance. It should be focused on the significance of the mouth covering during coughing and adequate ventilation as a way of infection control. Proper hydration and nutrition are important as well.

Pharmacotherapy (also including complementary and alternative therapy)

The patient should be placed on the first-line anti-tuberculosis therapy, which comprises isoniazid, rifampicin, pyrazinamide, and ethambutol for at least six months. Treatment should be monitored with direct observation or directly observed therapy (DOT). The aids to recovery can be complementary therapies such as nutrition and rest.

Health promotion (prevention care, proactive advice)

The health promotion is based on early screening of close contacts, the amelioration of living conditions, and creating awareness as far as the prevention of tuberculosis is concerned. Such a vaccination as BCG may be assumed.

Follow-Up

The client should also be visited frequently to follow up to see how the treatment is responding, whether the client is taking the medication, and whether there are any side effects. Sputum tests must be repeated to ascertain their effectiveness.

References

Alhajjaj, M. S., Abdulghani Sankari, & Bajaj, P. (2024, October 7). Chronic Cough. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430791/

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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?

 

  1. What questions would you ask the client?

 

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

 

  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)
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

 

 

References

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

APA format please, at least one reference