Physical Assessment Case Study Essay

Name:                                                                              

Week of Class (1-8):               

 

• Body System focus area: Respiratory system      

 

Case Study: 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.

 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 persistent dry cough that has been there for the last two weeks.

2. What questions would you ask the client?
   • HPI (history of present illness): how long have you had the cough? Have you been taking any medications to manage the cough? Are you using any supplements or herbs for the cough? What are the characteristics of the cough?
   • ROS (review of systems): General: are you feeling weak or fatigued? Do you have a fever? Have you lost weight? Cardiovascular: are you experiencing chest pains, discomfort, or pressure? Respiratory: are you experiencing shortness of breath or a cough, and what are its characteristics?
   • Medical/Surgical/Psych History: do you have any underlying medical condition? Have you ever undergone a major surgery, and when was it? Do you have or have had a psychiatric condition? Are all immunizations up to date?
   • Family History: do you have any chronic illness? Does the child have a chronic illness or siblings with chronic illnesses? Does anyone in your immediate family have a history of diabetes, cardiovascular disease, cancer, or renal disease?
   • Social History: where was the patient born? Who do you live with? Does she have other siblings? Does she have friends? How is her relationship with other children her age and her siblings?

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3. What physical examinations would you include?

 

Body System	Include? ✓   (yes) or – (not indicated)	Notes
General survey	✓	Overall patient observation Vital signs Weight and height measurements
HEENT (head, eyes, ears, nose, throat/thyroid)	✓	Inspection Skull palpation Observe and inspect the eyes Inspect the ears, neck, nose and throat
Cardiovascular	✓	Auscultate heart sounds (stethoscope to actual skin)
Peripheral Vascular
Breasts
Lymphatic
Pulmonary	✓	Auscultate lung sounds (stethoscope to actual skin) – anterior and posterior Palpation Percussion
Gastrointestinal/Abdominal
Genitourinary/Pregnancy
Integumentary
Musculoskeletal
Neurological

 

4. What are pertinent positive physical assessment findings?

Fever, general body weakness, a dry, non-productive cough, post-nasal drip, abnormal breath sounds

5. What are the pertinent negative physical assessment findings?

No increased respiratory rate, no hyperessonance upon percussion

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

Gastroesophageal Reflux Disease (GERD): The client presents with a persistent dry cough, which worsens at night to the point of waking up all people in the house. GERD is a differential diagnosis since it is characterized by a dry cough that worsens with lying down.

Asthma: Asthma is usually characterized by a dry cough, especially after a reaction to triggers such as environmental allergens, especially in children (Sharma et al., 2023). The cough mainly persists at night. The client in this care presents with a persistent dry cough that worsens at night; thus, asthma is a differential. The condition is ruled out since the client lacks other pertinent asthma symptoms, such as shortness of breath.

Whooping cough: The client presents with bouts of dry coughing and a whooping sound during inhalation; thus, the condition is differential. However, the condition is ruled out since the patient does not vomit after cough episodes.

7. What is your primary diagnosis?

The primary diagnosis is Upper Respiratory Tract Infection. The condition is characterized by a dry cough, which becomes productive as the infection progresses, fatigue, mild fever, and a sore throat (Cheng et al., 2021). In this case, the patient presents with all the symptoms; thus, the condition is the primary diagnosis.

 

8. What is your treatment plan?

The diagnostic procedures and lab tests required for a patient presenting with a dry cough include blood tests, sputum tests, and spirometry/methacholine challenge tests. According to Godman et al. (2020), patient education for parents with children suffering from chronic coughs is vital. The education entails discouraging the parent from using antibiotics for upper respiratory tract infections. Cheng et al. (2021) note that dry chronic cough in children may have underlying infections, thus requiring proper assessment. Pharmacotherapy will include first-generation antihistamines, antipyretics (paracetamol) or anti-inflammatory agents (ibuprofen), cough suppressants such as dextromethorphan, expectorants (guaifenesin) and decongestants such as pseudoephedrine and phenylpropanolamine (Cheng et al., 2021). Patient follow-up after two weeks is necessary to check the patient’s progress and determine if therapy changes are required.

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References

Cheng, Z. R., Chua, Y. X., How, C. H., & Tan, Y. H. (2021). Approach to chronic cough in children. Singapore Medical Journal, 62(10), 513–519. https://doi.org/10.11622/smedj.2021200

Godman, B., Haque, M., McKimm, J., Abu Bakar, M., Sneddon, J., Wale, J., Campbell, S., Martin, A. P., Hoxha, I., Abilova, V., Anand Paramadhas, B. D., Mpinda-Joseph, P., Matome, M., de Lemos, L. L. P., Sefah, I., Kurdi, A., Opanga, S., Jakupi, A., Saleem, Z., Hassali, M. A., and Hill, R. (2020). Ongoing strategies to improve the management of upper respiratory tract infections and reduce inappropriate antibiotic use, particularly among lower and middle-income countries: findings and implications for the future. Current Medical Research And Opinion, 36(2), 301–327. https://doi.org/10.1080/03007995.2019.1700947

Sharma, S., Hashmi. M.F., Alhajjaj. M.S. & Knizel, J. E. (2023). Cough (Nursing) In StatPearls [Internet]. Retrieves from: https://www.ncbi.nlm.nih.gov/books/NBK568776/

 

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)?

o o o

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