MSN 560 Week 1 Case Study (Physical Assessment)
Case Study Template
Body System focus area (i.e., cardiovascular): ___Endocrine___
Case Study:
Case 1: A 42-year-old female complains of progressive weight gain of 20 pounds
over the last year, fatigue, postural dizziness, loss of memory, slow speech,
deepening of her voice, dry skin, constipation, and cold intolerance. She claims
her menses have been irregular x 1 year. She has an 18-year-old daughter, and has
been attempting to have another child with her new partner. She has been
unsuccessful.
Note: Include in-text citations as needed (author, year).
Questions (if data is unavailable, indicate “unavailable”):
1. What is the client’s chief complaint? Client’s CC is weight gain of 20 lbs.
over the last year. Subsequentially, the secondary complaints include
fatigue, memory loss, postural dizziness, slow and deepening of speech, dry
skin, constipation, cold intolerance and irregular menses X 1 year.
2. What questions would you ask the client?
o HPI (history of present illness): Please describe how your symptoms
started? Did your symptoms progress rapidly or gradually within the
last year? With your episodes of dizziness, can you describe the
onset, precipitating and palliating factors, quality, region, severity and
timing (OPQRST) of the episodes (Bickley et al., 2023)? Have you ever
collapsed during your episodes of dizziness, and if so can you
describe the events? Does the fatigue you experience also linger after
getting a full night’s rest? You mention your menses have been
irregular, can you describe that? Can you tell me how long have you
been trying to conceive with your partner?
, o ROS (review of systems): Have you noted any changes with the
thickness of your neck or any abnormal changes in the shape of your
neck and throat area (e.g., goiter)? Have you noticed any thinning of
your hair or any hair loss? Has there been any changes with your nails
or tongue such as thickness? In addition to your memory loss, have
you experienced any brain fog or changes with your mood? Have you
noticed any changes with how your muscles feel such as aches,
tenderness, weakness and/or stiffness (Mayo Foundation for Medical
Education and Research, n.d.)? Have you noticed any changes with
your face such as puffiness or a change in color? How would you
describe your intimate relationship with your partner?
o Medical/Surgical/Psych History: Have you had any previous surgeries
or have been previously hospitalized? Are you currently taking any
medications including OTC, vitamins and herbals? Have you had any
thoughts of harming yourself or have lost interest in activities you
once enjoyed? Do you feel safe at home?
o Family History: Do you have any family history of thyroid or
autoimmune disease? Do you have any family history of mental
disorders? o Other: N/A – All questions I would ask the patient have
been described above.
3. What physical examinations would you include?
Body System Include? ü (yes) or - Notes
(not indicated)
General survey Physical appearance,
cognition, body
ü
structure, behavior,
vitals
Case Study Template
Body System focus area (i.e., cardiovascular): ___Endocrine___
Case Study:
Case 1: A 42-year-old female complains of progressive weight gain of 20 pounds
over the last year, fatigue, postural dizziness, loss of memory, slow speech,
deepening of her voice, dry skin, constipation, and cold intolerance. She claims
her menses have been irregular x 1 year. She has an 18-year-old daughter, and has
been attempting to have another child with her new partner. She has been
unsuccessful.
Note: Include in-text citations as needed (author, year).
Questions (if data is unavailable, indicate “unavailable”):
1. What is the client’s chief complaint? Client’s CC is weight gain of 20 lbs.
over the last year. Subsequentially, the secondary complaints include
fatigue, memory loss, postural dizziness, slow and deepening of speech, dry
skin, constipation, cold intolerance and irregular menses X 1 year.
2. What questions would you ask the client?
o HPI (history of present illness): Please describe how your symptoms
started? Did your symptoms progress rapidly or gradually within the
last year? With your episodes of dizziness, can you describe the
onset, precipitating and palliating factors, quality, region, severity and
timing (OPQRST) of the episodes (Bickley et al., 2023)? Have you ever
collapsed during your episodes of dizziness, and if so can you
describe the events? Does the fatigue you experience also linger after
getting a full night’s rest? You mention your menses have been
irregular, can you describe that? Can you tell me how long have you
been trying to conceive with your partner?
, o ROS (review of systems): Have you noted any changes with the
thickness of your neck or any abnormal changes in the shape of your
neck and throat area (e.g., goiter)? Have you noticed any thinning of
your hair or any hair loss? Has there been any changes with your nails
or tongue such as thickness? In addition to your memory loss, have
you experienced any brain fog or changes with your mood? Have you
noticed any changes with how your muscles feel such as aches,
tenderness, weakness and/or stiffness (Mayo Foundation for Medical
Education and Research, n.d.)? Have you noticed any changes with
your face such as puffiness or a change in color? How would you
describe your intimate relationship with your partner?
o Medical/Surgical/Psych History: Have you had any previous surgeries
or have been previously hospitalized? Are you currently taking any
medications including OTC, vitamins and herbals? Have you had any
thoughts of harming yourself or have lost interest in activities you
once enjoyed? Do you feel safe at home?
o Family History: Do you have any family history of thyroid or
autoimmune disease? Do you have any family history of mental
disorders? o Other: N/A – All questions I would ask the patient have
been described above.
3. What physical examinations would you include?
Body System Include? ü (yes) or - Notes
(not indicated)
General survey Physical appearance,
cognition, body
ü
structure, behavior,
vitals
