What are pertinent negative physical assessment

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Reference no: EM133756603

Case : A 38-year-old artist has smoked since she was 18 years old. She has noticed a mild, occasionally productive cough for the past few months. On a recent trip to the mountains, she developed shortness of breath that caused her to be nauseated. She has had no fever or chills. Her medical history includes hypertension for which she is using lisinopril, metoprolol, and hydrochlorothiazide.

1. What is the client's chief complaint?

2. What questions would you ask the client?

HPI (history of present illness)

ROS (review of systems)

Medical/Surgical/Psych History

Family History o Other

3. What physical examinations would you include? Body System Include? (yes) or - (not indicated) Notes General survey HEENT (head, eyes, ears, nose, throat/thyroid) Cardiovascular Auscultate heart sounds (stethoscope to actual skin) Peripheral Vascular Breasts Lymphatic Pulmonary Auscultate lung sounds (stethoscope to actual skin) - anterior and posterior Gastrointestinal/Abdominal Genitourinary/Pregnancy Integumentary Musculoskeletal Neurological

4. What are pertinent positive physical assessment findings?

5. What are the pertinent negative physical assessment findings?

6. What are at least 3 differential diagnoses (use Up-to-Date App if needed)?

7. What is your primary diagnosis?

8. What is your treatment plan?

Diagnostic procedures

Reference no: EM133756603

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