1. What is the client’s chief complaint? 2. What questions would you ask the client? o HPI (history of present illness) o ROS (review of systems) o Medical/Surgical/Psych History o Family History

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 HPI (history of present illness)

o ROS (review of systems)

o Medical/Surgical/Psych History

o Family History

o Other

3. 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

 

 

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 Diagnostic procedures

o Labs

o Client education (including lifestyle modifications, if applicable)

o Pharmacotherapy (including complementary and alternative therapies)

o Health promotion (preventative care, anticipatory guidance)

o 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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