Case Study
case study for physical assessment of an adult. Write down your abnormal findings from head to toe assessment.
Write your subjective, objective data, assessment , plan of care regarding for this patient!
Patient two is a 51 year old female that reports fatigue, difficulty swallowing, increased sensitivity to cold, weight gain of twelve pounds in two months, and weakness over the past four months.
The patient is escorted to an exam room, I introduce myself and properly identify and apply a wristband to the patient. The patient is asked about allergies and medication. She reports that she has no allergies, and currently takes a blood pressure medicine. She also reports she has been to a dermatologist because her skin has been dry and she was instructed to use over the counter moisturizers that aren’t working very well.
After interviewing the patient, the physical assessment begins. Vital signs are obtained: Blood pressure 118/82, heart rate 51 beats per minute, 16 respirations per minute, temperature 98.5 degrees, weight of 184 pounds.
The patient has short hair that is clean and well groomed. She denies any hearing problems, visual problems, congestion or cough. No drainage is noted from her ears, the eyes are clear with no redness or conjunctiva. Pupils are equal and reactive to light. Nares are clear bilaterally without swelling. The patient has good dentition. The lips, tongue, oral mucosa, and uvula are unremarkable. Facial symmetry is good with no drooping. The patient’s neck is supple with full range of motion and the trachea is midline. The thyroid is examined closely based upon the patient’s subjective information. The patient is seated and asked to slightly extend her neck. A portable light is used to provide cross lighting for the initial visual examination. The patient is asked to swallow and no appreciable difference is noted with the light applied from the right or left side. After completing anterior inspection of the thyroid, the neck is observed in profile. A smooth, straight contour is visualized from the cricoid cartilage to the suprasternal notch. An anterior palpation is done next. First the thyroid isthmus is located by palpating between the cricoid cartilage and the suprasternal notch. One hand is used to move the sternocleidomastoid muscle and the other hand is used to palpate the thyroid (Jarvis, 2012). The patient is asked to swallow and the upward movement of the thyroid gland is felt. To palpate the other side, the procedure is reversed. The left lobe of the patient’s thyroid feels fuller and moves slightly less than the right side. The patient reports pain on the left side during palpation.
Alternatively, a posterior approach to examination of the thyroid can be performed (Jarvis, 2012). Standing behind the patient, locate the thyroid isthmus by palpating between the cricoid cartilage and the suprasternal notch. Once this landmark has been located, the hands are moved laterally to feel under the sternocleidomastoids for the thyroid. The patient is asked to swallow, and upward movement of the thyroid gland is felt.
Respirations are clear and even bilaterally. The heart is auscultated and is strong and even at 52 beats per minute. Normal S1 and S2 are present. The patient denies any pain or mass in the breasts and reports that she self-examines monthly and her last mammogram was within the last twelve months. Hand grips are strong and equal, radial pulses are strong and equal bilaterally. The abdomen is soft and non-tender to palpation. Bowel sounds are present in all four quadrants. Foot strength equal bilaterally, with strong bilateral pedal pulses. The patient’s mood and affect are appropriate for her age and the current situation. The skin is somewhat dry and flaky, despite the patient’s report of applying moisturizing lotion. Her speech is clear
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