Miss Washington is a 71 y/o female who presents with a new leg ulcer that appeared after a fall 1 week ago. The patient is coughing and wheezing. She tells you that “I’m feeling terrible.” Vitalsigns appear stable with no fever.
Include the following:
Identify the patient’s chief complaint.
Identify what physical exams and diagnostic tests would be most appropriate to gather more information about the patient’s condition. Be specific and explain your reasoning.
Explain how the results would be used to make a diagnosis.
Identify three to five (3–5) possible conditions that may be considered in a differential diagnosis for the patient. Explain your thinking.
Required Readings
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). Elsevier Mosby.
Chapter 3, “Examination Techniques and Equipment”
This chapter explains the physical examination techniques of inspection, palpation, percussion, and auscultation. This chapter also explores special issues and equipment relevant to the physical exam process.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). F. A. Davis Company. Chapter 2, “The Comprehensive History and Physical Exam”
RUBRIC
15 to >12.0 pts
Excellent
The response clearly, accurately, and in detail explains the assigned patient’s chief complaint.
20 to >17.0 pts
Excellent
The response clearly, accurately, and in detail Identifies physical exams and diagnostic tests that are most appropriate to gather more information about the patient’s condition; reasoning for the exams/tests is clear, accurate, and detailed.
15 to >12.0 pts
Excellent
The response clearly, accurately, and in detail explains how the results would be used to make a diagnosis.
35 to >29.0 pts
Excellent
The response clearly, accurately, and in detail identifies four or five possible conditions that may be considered in a differential diagnosis for the patient; with clear, accurate, and detailed reasoning for each possible condition.
5 to >4.0 pts
Excellent
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
5 to >4.0 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.
5 to >4.0 pts
Excellent
Uses correct APA format with no errors.
