Physical Assessment Case Study 2

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Case Study Two: A Complete Physical Assessment
Shannon A. Lewis
University of Mississippi Medical Center
N 610

A 52-year-old female comes to your office today for a physical exam. She states that she enjoys good health and believes she is active for her age. She states she has been feeling well but just decided it was time for a complete check-up. She sees a local health care provider annually at the health department for refills on her prescriptions but has not had a “real” physical in many years. She is a WDWNWFNAD (well-developed, well-nourished, white female, no acute distress. Both the history and physical assessment have been thoroughly reviewed.
Assignment:
1. Make a problem list.

Her problem list is extensive,
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“The USPSTF strongly recommends screening for colorectal cancer using either high-sensitivity fecal occult blood testing (FOBT), sigmoidoscopy, or colonoscopy; screening should begin at age 50 years and continue until age 75 years” (Uphold & Graham, 2013, p. 31). She also needs a CMP, a CBC, a lipid profile, a urinalysis, and a thyroid function test. If the glucose level is high, a hemoglobin A1C should be ordered, which is “reasonable to order in asymptomatic intermediate-risk adults without diagnosis of diabetes” (Uphold & Graham, 2013, p. 483). All of these screenings and tests will help the provider to have a more clear view of the patient’s overall health (Uphold & Graham, 2013).

• The patient needs to been seen by an ophthalmologist to test for cataracts because she has funduscopic bilateral lens opacification upon examination. She also reports seeing halos around lights at night. Additionally, she has a family history of cataracts. Though the patient wears bifocals, she reports her last eye exam was four years ago. It is possible she needs a new prescription for her glasses. Vision problems may be the cause of her
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I will assess her blood pressure log to check her readings and to be certain she kept an up-to-date diary of her readings. I will take two or three blood pressure readings at four different appointments and will prescribe an anti-hypertensive if her blood pressure remains elevated during the weekly follow-ups over a month (Mayo Clinic, 2016). After I review all of the patient’s test results, I will refer her to the appropriate specialists for further follow-up care if indicated. I will also encourage the patient to return annually for her health assessment as well as for continued health promotion and disease

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