Physical Assessment Essay

Physical Assessment Essay

Case Study Template

Name: ________________________________________

Week of Class (1-8): ______

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

Case Study: Case 3: A 42-year-old male complains of painless swelling on the left side of his neck x 30 days. History: controlled diabetes mellitus and hypertension. He has had a slight fever and generalized body ache x 15 days. He has recently developed foul-smelling diarrhea, approximately eight episodes per day, with a 4 kg weight loss in 15 days. Diet: vegetarian. Allergies: none. Upon physical examination, + neck welling (posterior triangle of the left side of the neck), non-tender, not matted

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

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

1. What is the client’s chief complaint?

The client’s chief complaint is a painless swelling on the neck, which has been there for the last 30 days.

2. What questions would you ask the client?

o HPI (history of present illness)– how long have you had the swelling? Have you ever been diagnosed with any condition related to the thyroid? Are you taking any medications, herbs, or supplements?

o ROS (review of systems)– (general)-have you been having fevers or feeling fatigued? Have you had chronic or past neck or head disorders? (Gastrointestinal)-Have you had abdominal pains? How many diarrhea episodes have you been having in a day? How long have you had diarrhea? Have you had a loss of appetite?

o Medical/Surgical/Psych History– do you have any other medical condition? Have you ever undergone a major surgery, and when was it? Do you have or have had a mental condition?

o Family History– is there anyone in your immediate family with cardiovascular conditions? Is there a history of hypertension, diabetes, cancer, or any renal disease in your family?

o Social History– what is your occupation? Do you live alone? What is your relationship status? How many children do you have? Do you use any drugs or substances?

3. What physical examinations would you include?
   

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Body System	Include? (Yes) or- (not indicated)	Notes
General survey	yes	Overall observation of the patient Vital signs Weight and height measurements
HEENT(Head, Eyes, Ears, nose, throat/thyroid)
cardiovascular
Peripheral vascular
Breasts
lymphatic	yes	Look for edema in extremities Palpate obvious mass swellings on the neck
Pulmonary
Gastrointestinal/abdominal	yes	Auscultation and palpation of the abdominal area Bowel sounds Identify any abnormal abdominal masses
Genitourinary/Pregnancy
Integumentary
Musculoskeletal
Neurological

 

4. What are pertinent positive physical assessment findings?

Non-tender, matted swelling noted on the left posterior triangle of the neck. Fever. Hyperactive bowel sensations. Dehydration and muscle wasting.

5. What are the pertinent negative physical assessment findings?

Distended abdomen, no abdominal masses or scars

6. What are at least 3 differential diagnoses (use Up-to-Date App if needed)?

Gastroenteritis- the client presents with fever, and foul-smelling diarrhea, which are major symptoms of gastroenteritis. However, the patient denies vomiting, and headaches, thus a differential.

Giardiasis- the patient presents with fatigue and diarrhea, thus considering giardiasis as a differential diagnosis. However, it is ruled out since the patient lacks nausea, bloating, and loss of appetite. Groudan et al. (2020) note that nausea, bloating, and loss of appetite are major giardiasis symptoms.

Lymphadenitis- the client presents with a non-tender swelling on the neck, fever, and general body ache, leading to the consideration of lymphadenitis as a differential. However, it is ruled out since the patient’s swelling does not appear red and is painless.

7. What is your primary diagnosis?

The primary diagnosis is lymphadenopathy. It is characterized by swelling in the neck, unexplained weight loss, and fever (Keshavar et al., 2021). The patient in this case study presents with all the symptoms. In addition, lymphadenopathy is a sign of an underlying illness or infection. Since the patient presents with other symptoms apart from neck swelling, such as diarrhea, lymphadenopathy is thus the primary diagnosis.

8. What is your treatment plan?

The diagnostic procedures and lab tests required for lymphadenopathy include lymph node biopsy, physical exam, imaging, and blood tests to identify the underlying infection. Client education is vital for lymphadenopathy patients. For instance, client education should include informing the patient about the symptoms, treatment options, and medication adherence. In addition, health promotion is needed to inform patients and the general population about the condition. For instance, the client in this case study has been having swelling for the last 30 days without seeking medical attention, probably due to a knowledge deficiency on the condition. Therefore, awareness creation would help address the condition or underlying infection early. Maini and Nagalli (2021) state that lymphadenopathy therapies include radiation, antibiotics, and immune therapy. Pharmacotherapy will include allopurinol, atenolol, captopril, carbamazepine, and sulfonamides (Maini & Nagalli, 2021). In addition, the patient required a follow-up in a month to assess the swelling and determine if therapy changes were required.

References

Groudan, K., Gupta, K., Chalhoub, J., & Singhania, R. (2020). S2080 Is There a Role for Duodenal Biopsy in the Diagnosis of Giardia? Official journal of the American College of Gastroenterology| ACG, 115, S1094. https://doi.org/10.14309/01.ajg.0000710368.73140.58

Keshavarz, P., Yazdanpanah, F., Rafiee, F., & Mizandari, M. (2021). Lymphadenopathy Following COVID-19 Vaccination: Imaging Findings Review. Academic Radiology, 28(8), 1058–1071. https://doi.org/10.1016/j.acra.2021.04.007

Maini, R., & Nagalli, S. (2021). Lymphadenopathy. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK558918/

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Physical Assessment Case Study Template
Name:
Week of Class (1-8):
Body System focus area (i.e., cardiovascular): Case Study:

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?
✓ (yes) or – (not indicated) Notes
General survey ✓
HEENT (head, eyes, ears, nose, throat/thyroid)
Cardiovascular ✓ Auscultate heart sounds (stethoscope to actual skin)
Peripheral Vascular
Breasts
Lymphatic

Pulmonary
✓ 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)?

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