case analysis 4

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The purpose of the case analyses is to assist in learning the key components from the assigned reading and other adjunct learning tools. Case analyses will focus on a
variety of topics incorporating assessment across the lifespan (pediatric, geriatric, obstetric, etc.).
Read each case analysis and choose two to complete
J. L. had a CVA within the past week. J. L. is easily frustrated, anxious, and fearful, and her speech is slurred. She needs verbal cuing for any task she is asked to
carry out. She eats only food on the left side of the tray and responds only when approached from the left side.
C. C., age 55 years, has come for a follow-up visit after an ankle fusion to improve her gait. She has a benign tumor in the spinal cord at T10 that has gradually
impaired her gait over a period of 15 years. She reports occasional urinary incontinence. Sensation and mobility are decreased, especially in the right extremity, and
atrophy of the right lower extremity is noted.
R. R. has been referred to the neurologic clinic for evaluation. History provided by his wife includes confusion, loss of short-term memory, poor judgment, and
ritualistic and repetitive behaviors. Tentative diagnosis is Alzheimer’s disease.
A 63-year-old man with a long history of insulin-controlled diabetes has come to the emergency department because of burns on his feet. He soaked his feet in the
morning and then put on his socks and heavy work boots. After a day’s work, when he took off his shoes and socks, he discovered that the skin of his feet was
completely burned off. He states he did not notice a thing all day because his feet are “always numb and tingling.”
Choose two cases from the list above and complete the following:
5 review of systems (ROS) questions
5 physical assessment techniques that would be conducted in a focused physical exam
Each case is worth 10 points
Each case must include 5 ROS questions and 5 physical assessment techniques

P.D. is an 18 month old, Caucasian, male toddler brought to the health practitioner by his mother. He appears listless as he is leaning into his mother’s shoulder,
while she supports him with both her arms, laying her chin upon his head. Practitioner speaks to P.D.’s mother, “Good afternoon Mrs. D I am Mrs. W., how long has P.D.
been like this?”
Parental bonding is being demonstrated positively by this child and parent. “Parental bonding, the child’s interactions with the parents, show mutual response and are
warm and affectionate, appropriate to the child’s condition.” (Jarvis, 2011, p. 143) Communication with a toddler P.D.’s age consists of, “nonverbal communication as
the primary method, since older infants have anxiety toward strangers. They are more cooperative when the parent is kept in view.” (Jarvis, 2011, p. 39) As P.D.
progresses through Erickson’s theory of psychosocial development he should be nearing the end of “trust verse mistrust stage and beginning the autonomy verse shame and
doubt stage”. (About.com, 2012) This may be difficult to assess at this time due to current illness and listlessness of the toddler.
Practitioner continues with questioning the mother regarding P.D.’s current illness, past medical and postnatal history. At completion of obtaining health history the
toddler is assessed on the mother’s lap.
Subjective questions asked in a review of systems would include:
1. Has he had any fever and when did it start?
2. Has he had any nasal congestion, runny nose or cough?
3. How much is he drinking and eating, compared to his normal intake?
4. How many times has he urinated, had a bowel movement or vomited in the last 12 hours? Please describe the consistency of the stool, color or the urine and quantity
of emesis.
5. Did you notice P.D. in any pain, pulling at his ears or any rashes on his body?
Assessment techniques that would be conducted in a focused physical exam would include the following:
1. Inspection: “Begin by greeting the child and the accompanying parent by name, but focus more on the parent”, to allow the child time to warm up to you. (Jarvis,
2011, p. 123) Keep the child dressed for as long as you can and have the parent undress the child one part at a time. (Jarvis, 2011, p. 124) Looking at the child for
visible skin moisture, color and rashes.
2. Measurements: Obtain respiratory rate for full minute, first, while listening to the parent, this is to ensure accurate respiratory rate while allowing time for the
child to remain calm. Remember to watch for use of accessory muscles and nasal flaring. Followed by the heart rate, using a brachial pulse for 30 seconds x 2, tympanic
temperature, length, weight and head circumference. Leaving the more invasive procedures for last.
3. Auscultation: Listen to the child’s lungs and heart with stethoscope while the child sits on the mother’s lap. The practitioner should listen in a Z pattern taking
care to listen to all areas of the heart auscultating for murmurs, extra beats and any other abnormalities.
4. Examination: Assess the child’s mouth, throat and ears with otoscope/ophthalmoscope while the child is sitting on his mother’s lap. Gently pulling the top of the
ear upward for best view of the tympanic membrane. Unless he becomes uncooperative then lay child on the examination table while the mother assists in keeping child
still. Keeping safety in mind at all times.
5. Focused Assessment: Assess the child for dehydration. Check skin turgor and mobility over the abdomen by slightly pinching the skin and observing the skin
retraction time, assess mucus membranes and tear production when crying. Also refer back to the subjective response from his mother in regards to oral intake and
urination pattern. (Jarvis, 2011)
Note: For grading purposes, please be sure that ROS and PE are pertinent to the case study. For the review of systems, do not list singly: pain assessment,
aggravatoring factors, rating, medications, etc. This is one question as PQRSTU. For the physical assessment, do not include diagnostic/laboratory testing. Points will
be deducted.

References
Jarvis, C. (2011). Physical examination & health assessment (6th Ed.). St. Louis, Missouri: Elsevier
About.com. (2012). Erickson’s Psychosocial Stages Chart. Retrieved January 26, 2012, from https://psychology.about.com/library/bl_psychosocial_summary.html
Braswell, R., Carcione, J., Halsey, J.H. & Talavera, F. (Eds). (2005). Migraine Headaches, Visual Effects. Retrieved January 27,2012, from
www.emedicinehealth.com/migraine_vision_effects.htm