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Case study and Physical exam write up

Case study and Physical exam write up

Case study and Physical exam write up

Please read the following case study. Once you understand the nature of the patient or client’s condition, complete a mock physical exam, describing the anticipated findings, based on the history and lab values provided. The physical exam write-up must include the relevant organ systems associated with the pathology of the patient.

Your write up should:

  • Include a brief description of what the general assessment may entail in this individual and the expected results.
  • Consider the focused physical exam you would perform after assessing the individual’s medical history and include the expected results.

Case study:

L. J. is a 78 year- old, obese male with a long history of type 2 diabetes. He presents to you for a routine follow up. He was diagnosed with Hashimoto’s thyroiditis when he was in his early 30’s and prescribed medication for the condition at that time. He was diagnosed with Cushing’s Syndrome when he was 69 years – old and gradually discontinued the prescribed corticosteroids due to the unremitting side effects he experienced. He admits to frequently forgetting to take his medications but confirms for you that he takes a multivitamin daily.   He has a history of heavy alcohol and tobacco abuse but stopped drinking and smoking about 5 years ago. He noticed an increase in the swelling around his ankles and feet but attributes this to old age. There is a poorly healing scar on his right foot that he was not aware of, until pointed out to him. His blood pressure on presentation was noted as 160 / 100. He is asymptomatic.

His most recent laboratory values are as follows:

  • Urinalysis  – trace proteins
  • Random serum glucose level  – 189 mg/dl
  • Serum electrolytes – in normal range
  • Thyroid panel lab values –  normal range
  • The results of a 24 hour urine collection are pending.

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