Pertinent Positive Physical Assessment Findings Assignment

Pertinent Positive Physical Assessment Findings Assignment

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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?

2. 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

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

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)?

7. What is your primary diagnosis?

8. 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