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Using inspection, palpation, percussion, and auscultation, the examiner evaluates all systems associated with the subjective complaint including all systems which may be causing the problem or which will manifest or may potentially manifest complications and records positive and pertinent negative findings

Using inspection, palpation, percussion, and auscultation, the examiner evaluates all systems associated with the subjective complaint including all systems which may be causing the problem or which will manifest or may potentially manifest complications and records positive and pertinent negative findings

GUIDELINES FOR INDIVIDUAL CASE STUDY

Required elements of the case study:

All papers are to be type written, double spaced, with pages numbered. Please write course name and number, your name, and date clearly on materials submitted. Use American Psychological Association (APA) style 6th edition including paper format and references. Points may be deducted for multiple spelling, grammar, format and typing errors.

1.    Subjective (0.5 point)

State the patient’s chief complaint, reason for visit and/or the problem for which the patient sought consultation.

a. All symptoms related to the problem are described using the following cue descriptive categories:

1. Precipitating/alleviating factors (including prescribed and/or self-remedies and their effect on the problem).

2. Associated symptoms

3. Quality of all reported symptoms including the effect on the patient’s lifestyle

4. Temporal factors (date of onset, frequency, duration, sequence of events)

5. Location (localized or generalized? does it radiate?)

6. Sequelae (complications, impact on patient and/or significant other)

7. Severity of the symptoms

b. Past Medical History including immunizations, allergies, accidents, illnesses, operations, hospitalizations.

c. Family History includes family members’ health history.

d. Social history to include habits, residence, financial situation, outside assistance, family inter-relationships.

e. Review of Systems relevant to the chief complaint/presenting problem is included. Include pertinent positives and negatives.

2.  Objective (0.5 point)

a. Using inspection, palpation, percussion, and auscultation, the examiner evaluates all systems associated with the subjective complaint including all systems which may be causing the problem or which will manifest or may potentially manifest complications and records positive and pertinent negative findings

b. Performs appropriate diagnostic studies if equipment is available

c. Records results of pertinent, previously obtained diagnostic studies.

d. Use Handout Guidelines to Physical Examination.

3.  Assessment (1.5 points)

a. Diagnosis/es is (are) derived from the subjective and objective data highlighting the pathophysiology of the case/s.

b. Differential diagnoses are prioritized (minimum of 2)

c. Diagnosis/es come(s) from the medical and/or nursing domain

d. Assessment includes health risks/needs assessment

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