Miami Dade College Wk 4 Health and Medical Case Study

Case 1: An 89-year-old female complains of a “stabbing chest pain” and points to the area just below her scapula at the right mid-clavicular line. She states that she had an upper respiratory infection last week that “just seems to hang on.” No other complaints.?

Case 2: A 58-year-old male presents with a complaint of severe chest pain over the last hour. He states that he did not call 911 because he cannot afford an ambulance.?

Case 3: A 15-year-old immigrant was brought to the clinic by her mother because client complains of shortness of breath, chest pains, diaphoresis and easy fatiguability. She claims she has had on and off bouts of tonsillitis since she was a child that resulted in tonsillectomy surgery when she was 12. Last week, she was unable to participate in the cheer leading tryouts because of knee pain and a rash that she noticed on her trunk for the past 2 weeks.

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
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

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