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Case Study Guide

The documents provide guidelines for conducting a case study and physical assessment of a patient. The case study guide includes questions about the patient's biographic data, reasons for seeking care, history of present and past health concerns, family health history, lifestyle and daily activities, and developmental stage. The physical assessment guide outlines how to examine the patient's general appearance, vital signs, and each body system, including the skin, head, eyes, cardiovascular, pulmonary, abdominal, neurological and other systems. The goal is to collect comprehensive information about the patient's medical history and current physical status.

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Marc Jamel ROdriguez
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13 views

Case Study Guide

The documents provide guidelines for conducting a case study and physical assessment of a patient. The case study guide includes questions about the patient's biographic data, reasons for seeking care, history of present and past health concerns, family health history, lifestyle and daily activities, and developmental stage. The physical assessment guide outlines how to examine the patient's general appearance, vital signs, and each body system, including the skin, head, eyes, cardiovascular, pulmonary, abdominal, neurological and other systems. The goal is to collect comprehensive information about the patient's medical history and current physical status.

Uploaded by

Marc Jamel ROdriguez
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Case Study Guide Questions

A. Biographic Data:
● What is your name?
● Can you provide your current address?
● What is your gender?
● Who is the significant other providing this information?
● When and where were you born?
● What is your nationality or ethnicity?
● What is your marital status?
● Do you have any specific religious or spiritual practices?
B. Reason(s) for Seeking Health Care:
● What is your major health problem or concern at this time? (Chief Complaint)
● How do you feel about having to seek healthcare? Can you discuss any fears or
other feelings about having to see a healthcare provider?
C. History of Present Health Concern:
● Can you provide a detailed description of your health problem or symptom,
focusing on its onset, progression, and duration?
● What signs and symptoms are associated with your current health concern?
D. Past Health History:
● Can you provide information about your birth, growth, and development?
● Have you experienced any childhood diseases?
● Do you have any allergies?
● Can you list any previous health problems, hospitalizations, or surgeries you have
had?
● Have you experienced any pregnancies or reproductive health issues?
● Have you had any previous accidents, injuries, or significant pain experiences?
● Have you experienced any emotional or psychiatric problems in the past?
E. Family Health History:
● Are there any genetic predispositions or hereditary health conditions in your
family?
● Can you describe other health problems that may have affected you due to family
upbringing and exposure?
F. Lifestyle and Health Practices:
● Can you describe a typical day in your life?
● How do you manage your nutrition and weight?
● What is your activity level and exercise routine?
● How do you sleep and rest?
● Do you take any medications or substances regularly?
● How do you view yourself and your self-care responsibilities?
● What social activities do you engage in?
● Can you describe your relationships with family members and significant others?
● What values and belief systems do you hold?
● What is your educational and occupational background?
● How do you perceive your stress levels and cope with stress?
● Are there any environmental factors that may impact your health?
G. Developmental Level:
● Which developmental stage do you belong to according to Erickson's
developmental tasks?
Case Study Physical
Assessment Guide

General Survey:
● Observation for Appearance:
● Describe the patient's overall appearance, including age, body build,
skin color, and any obvious abnormalities or distress.
● Motor Movement:
● Assess the patient's motor function by observing their ability to
move all extremities, coordination, and any signs of weakness or
tremors.
● Hygiene:
● Evaluate the patient's cleanliness, including body odor and personal
grooming.
● Posture:
● Note the patient's posture while standing, sitting, and walking.
● Gait:
● Observe the patient's gait for any abnormalities, such as limping or
unsteady movements.
● Breath Odors:
● Note any unusual or foul breath odors.
● Signs of Distress:
● Look for signs of pain or discomfort, such as grimacing or guarding
certain areas.
● Psychosocial:
● Assess the patient's mental status, including mood, affect, and level
of consciousness.
● Vital Signs:
● Record the patient's vital signs, including blood pressure, heart rate,
respiratory rate, and temperature.

​ Skin, Hair, Nails:


● Examine the skin for color, temperature, moisture, and any lesions, rashes,
or abnormalities.
● Assess the hair for texture, distribution, and any signs of hair loss or
abnormalities.
● Inspect the nails for color, shape, texture, and any signs of clubbing,
pitting, or other abnormalities.
​ Head and Neck:
● Inspect the head for size, shape, symmetry, and any deformities or
tenderness.
● Palpate the scalp for tenderness, lumps, or masses.
● Assess the neck for range of motion, lymph node enlargement, and any
masses or pulsations.
● Palpate the thyroid gland for size, shape, and tenderness.
​ Eyes and Ears:
● Inspect the eyes for symmetry, alignment, sclera color, and any discharge
or abnormalities.
● Assess visual acuity using a Snellen chart or other appropriate method.
● Inspect the ears for symmetry, size, shape, and any discharge or
abnormalities.
● Perform otoscopic examination to assess the ear canal and tympanic
membrane.
​ Mouth, Throat, Nose, and Sinuses:
● Inspect the mouth for oral hygiene, mucous membranes, teeth, gums, and
any lesions or abnormalities.
● Assess the throat for symmetry, tonsillar size, and any redness or exudate.
● Examine the nose for symmetry, mucous membrane color, and any
discharge or abnormalities.
● Palpate the sinuses for tenderness or swelling.
​ Heart and Neck Vessels:
● Auscultate the heart sounds using a stethoscope, including the rate,
rhythm, and any murmurs or extra sounds.
● Palpate the carotid arteries for strength, rate, and any bruits.
● Inspect and palpate the jugular veins for distention or pulsations.
​ Thorax and Lungs:
● Inspect the thorax for symmetry, shape, and any abnormal movements or
deformities.
● Palpate for tenderness, masses, or abnormal vibrations (fremitus).
● Percuss the lungs for resonance, dullness, or hyperresonance.
● Auscultate breath sounds in all lung fields, noting any adventitious sounds
such as crackles, wheezes, or rhonchi.
​ Abdomen:
● Inspect the abdomen for contour, symmetry, and any scars, lesions, or
distention.
● Auscultate bowel sounds in all quadrants.
● Palpate the abdomen for tenderness, masses, and organ enlargement.
​ Extremities:
● Inspect the arms and legs for symmetry, alignment, and any deformities or
abnormalities.
● Palpate peripheral pulses (radial, ulnar, brachial, femoral, popliteal,
posterior tibial, dorsalis pedis) for rate, rhythm, and amplitude.
● Assess skin temperature, color, capillary refill, and any edema.
​ Genitalia:
● Perform a genital examination as appropriate based on patient gender and
clinical indication.
● Inspect for any lesions, discharge, or abnormalities.
● Palpate for tenderness, masses, or swelling.
​ Anal and Rectal:
● Perform a rectal examination as indicated, assessing for hemorrhoids,
fissures, masses, or other abnormalities.
● Assess sphincter tone and stool consistency.
​ Neurologic:
● Assess mental status, orientation, and level of consciousness (alert,
lethargic, stuporous, comatose).
● Test cranial nerves for function, including sensation, motor function, and
reflexes.
● Assess muscle strength, tone, coordination, and gait.
● Perform sensory examination, including light touch, pain, temperature, and
proprioception.

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