Physical Assessment Essay

Case Study Template

Name: ________________________________________

Week of Class (1-8): ______

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

Case Study: 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.

Note: Include in-text citations as needed (author, year).

Questions (if data is unavailable, indicate “unavailable”):

1. What is the client’s chief complaint?

As mentioned in the case, the client’s chief complaint is “a mild, occasionally productive cough for the past few months” along with the recent development of “shortness of breath that caused her to be nauseated” during a trip to the mountains.

2. What questions would you ask the client?
   • HPI (history of present illness): A 38-year-old artist presents with a history of a mild, occasionally productive cough that has been ongoing for the past few months. She also reports a recent episode of shortness of breath during a trip to the mountains, which was severe enough to cause her to feel nauseated. The patient denies experiencing any fever or chills. Her symptoms have been gradually worsening, prompting her to seek medical attention.
   • ROS (review of systems): Respiratory: The patient reports the presence of a mild cough and shortness of breath.

Gastrointestinal: She experiences nausea, likely related to her shortness of breath.

Constitutional: Denies fever and chills.

• Medical/Surgical/Psych History: Hypertension: The patient has a history of hypertension.

Medications: She is currently taking lisinopril, metoprolol, and hydrochlorothiazide for hypertension management.

• Family History: unavailable
• Other: The patient is an artist and has a significant history of smoking since the age of 18.

3. What physical examinations would you include?
   

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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	ü	Palpation: Check for any abnormalities in the pulse, such as irregularities or discrepancies between peripheral pulses.
Breasts
Lymphatic
Pulmonary	ü	Auscultate lung sounds (stethoscope to actual skin) – anterior and posterior
Gastrointestinal/Abdominal	ü	Palpation: Assess the abdomen for tenderness, masses, or any abnormal findings.
Genitourinary/Pregnancy
Integumentary	ü	Inspect the skin for any rashes, discolorations, or signs of potential underlying systemic conditions.
Musculoskeletal
Neurological	ü	Assess the patient’s mental status, cranial nerves, motor strength, coordination, and reflexes.

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4. What are pertinent positive physical assessment findings?

Cough: The patient has a mild, occasionally productive cough, which could indicate a respiratory issue.

Shortness of breath (Dyspnea): The patient experienced shortness of breath during her recent trip to the mountains, which is a significant symptom of respiratory distress.

Nausea: The shortness of breath was severe enough to cause her to feel nauseated, which could be related to the underlying respiratory problem.

5. What are the pertinent negative physical assessment findings?

No fever: The patient denies having any fever. The absence of fever may help rule out certain infections or inflammatory conditions.

No chills: The patient also denies experiencing any chills. Chills can sometimes accompany infections, and their absence may be relevant in the diagnostic process.

6. What are at least 3 differential diagnoses (use Up-to-Date App if needed)?
   • Chronic Obstructive Pulmonary Disease (COPD): COPD is a progressive lung disease often caused by long-term smoking. Symptoms such as a chronic cough, shortness of breath, and sputum production are common in COPD. The patient’s smoking history and respiratory symptoms make this a relevant consideration (Ritchie et al., 2020).
   • Pneumonia: Pneumonia is an infection of the lungs that can cause symptoms such as cough, shortness of breath, and in some cases, nausea. The patient’s recent trip to the mountains might have exposed her to different environments or respiratory pathogens that could contribute to pneumonia (Lanks et al., 2019).
   • Asthma: Asthma is a chronic respiratory condition characterized by airway inflammation and constriction, leading to recurrent episodes of coughing, wheezing, and shortness of breath. Although the patient’s symptoms are more chronic in nature, asthma could be a differential diagnosis due to the presence of cough and shortness of breath, which worsened during her trip (Agache et al., 2021).
7. What is your primary diagnosis?

Primary Diagnosis: Pulmonary Embolism (PE)

The key factors supporting this diagnosis are:

Risk Factor (Smoking): The patient’s history of smoking is a significant risk factor for developing blood clots, which can lead to pulmonary embolism (Freund et al., 2022).

Symptoms (Cough, Shortness of Breath, Nausea): The patient’s mild, occasionally productive cough may be related to underlying respiratory issues and the sudden onset of shortness of breath during her recent trip to the mountains, which caused her to feel nauseated, raises concern for a potential pulmonary embolism (Freund et al., 2022).

Medical History (Hypertension): The patient’s medical history of hypertension and current use of antihypertensive medications may also contribute to the risk of developing a thrombotic event like a pulmonary embolism (Freund et al., 2022).

8. What is your treatment plan?
   • Diagnostic procedures:

D-dimer Test: This blood test measures the level of D-dimer, a fibrin degradation product. Elevated levels of D-dimer may indicate the presence of blood clots, but it is not specific to PE. A positive D-dimer test may prompt further investigation.

Chest X-ray: A chest X-ray may be performed to assess the lung structure and rule out other possible causes of the patient’s symptoms, such as pneumonia or other lung conditions.

CT Angiography (CTA): This is one of the most common and reliable tests used to diagnose PE. A contrast dye is injected into the patient’s veins, and a CT scan is performed to visualize the blood vessels in the lungs. This can detect the presence of blood clots and help determine their location and size (Freund et al., 2022).

• Labs:

Complete Blood Count (CBC): This test provides information about the patient’s red blood cells, white blood cells, and platelets. It can help identify signs of anemia, infection, or other abnormalities.

Arterial Blood Gas (ABG): An ABG test measures the levels of oxygen and carbon dioxide in the blood. It helps assess the patient’s respiratory status and acid-base balance.

Basic Metabolic Panel (BMP) or Comprehensive Metabolic Panel (CMP): These panels include various tests to assess kidney function, electrolyte levels, glucose levels, and liver function. These tests can provide valuable information about the patient’s overall health and help determine if any organ systems are affected (Freund et al., 2022).

• Client education (including lifestyle modifications, if applicable)

Lifestyle Modifications:

Smoking Cessation: Strongly encourage quitting smoking, as smoking increases the risk of blood clots and exacerbates cardiovascular and respiratory issues.

Physical Activity: Discuss the benefits of regular physical activity and encourage the patient to engage in activities suitable for their condition. Mild-to-moderate exercise can improve overall cardiovascular and respiratory health.

Hydration: Encourage staying well-hydrated, especially during prolonged periods of immobility or travel.

Medication Adherence: Educate the patient about the prescribed anticoagulant medication, its purpose, and the importance of taking it as directed. Stress that consistent adherence to the medication regimen is vital to prevent further clot formation and reduce the risk of complications.

• Pharmacotherapy (including complementary and alternative therapies)
  Anticoagulant Medication:

Low Molecular Weight Heparin (LMWH): Enoxaparin – This can be administered as a subcutaneous injection.

Direct Oral Anticoagulant (DOAC): Apixaban – This is an oral medication to be taken twice daily.

Pain Management:

Acetaminophen: This can be used for pain relief, and the patient may take it as needed for chest discomfort.

Oxygen Therapy:

If the patient’s oxygen levels are low, supplemental oxygen can be provided through a nasal cannula or face mask to maintain adequate oxygenation.

• Health promotion (preventative care, anticipatory guidance)

Preventative Care: Emphasize the importance of regular health check-ups and age-appropriate screenings to detect and manage health issues early on (Freund et al., 2022).

Physical Activity: Encourage regular physical activity to improve overall cardiovascular and respiratory health.

Healthy Diet: Promote a balanced diet rich in fruits, vegetables, and whole grains to support overall well-being.

• Follow-Up: Schedule a follow-up (2 weeks) appointment to monitor the patient’s progress, review test results, and adjust the treatment plan as needed. Regular follow-up visits are crucial for managing chronic conditions and ensuring proper response to therapy.

References

Agache, I., Eguiluz‐Gracia, I., Cojanu, C., Laculiceanu, A., Del Giacco, S., Zemelka‐Wiacek, M., & Jutel, M. (2021). Advances and highlights in asthma in 2021. Allergy, 76(11), 3390-3407. https://doi.org/10.1111/all.15054

Freund, Y., Cohen-Aubart, F., & Bloom, B. (2022). Acute pulmonary embolism: A review. JAMA, 328(13), 1336-1345. https://doi.org/10.1001/jama.2022.16815

Lanks, C. W., Musani, A. I., & Hsia, D. W. (2019). Community-acquired pneumonia and hospital-acquired pneumonia. Medical Clinics, 103(3), 487–501. https://doi.org/10.1016/j.mcna.2018.12.008

Ritchie, A. I., & Wedzicha, J. A. (2020). Definition, causes, pathogenesis, and consequences of chronic obstructive pulmonary disease exacerbations. Clinics in Chest Medicine, 41(3), 421-438. https://doi.org/10.1016/j.ccm.2020.06.007

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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.