Physical Assessment
Case Study Template
Name: Jacqueline Schwartz 01/11/2026
Week of Class (1-8): ONE
Body System focus area: Fundamentals
Case Study: A 42-year-old female complains of progressive weight gain of 20 pounds over the last
year, fatigue, postural dizziness, loss of memory, slow speech, deepening of her voice, dry skin,
constipation, and cold intolerance. She claims her menses have been irregular x 1 year. She has an 18-
year-old daughter and has been attempting to have another child with her new partner. She has been
unsuccessful.
Note: Include in-text citations as needed (author, year).
Questions (if data is unavailable, indicate “unavailable”):
1. What is the client’s chief complaint?
In one year a 20-pound weight gain, patient is a middle-aged female (42), deepening of voice,
irregular menses and possible infertility, dry skin, constipation, cold tolerance, fatigue,
postural dizziness, loss of memory, and slow speech.
2. What questions would you ask the client?
HPI (History of present illness)- How are your periods? Are they light or heavy? How are your
cramps and other symptoms when you have your period? How irregular are your periods, are
they ever 40 days, 20 days, do you miss your period completely without being pregnant? How
many months have you been trying to get pregnant for? Did you have any issues with getting
pregnant with your 18-year-old daughter?
ROS (Review of systems)- I would tell the patient I would like to do a head-to-toe assessment.
During the assessment I would check the patient’s thyroid. Is the thyroid tender when
swallowing, is it center on the throat. I would look at the presentation of the eyes. Are the eyes
sunk in or bulging. I would check the patient’s skin looking at the integrity, if she is having more
hair growth in places she has not before. I would check the patient’s neck looking for hunch
back. I would also want to do some balance and gait tests to see if she passes. Lastly, I would
send her to lab to collect a TSH, Free T4, CBC. Depending on the labs I would follow up with Anti-
TPO antibodies test and pituitary function test.
Medical, Surgical, Psych History- Does the patient suffer with mental health disorders like
depression or bipolar. Has the patient had and recent trauma like death in the family or a friend.
What does the patients support system look like. Has the patient had surgery. If so, has she had
Case Study Template
Name: Jacqueline Schwartz 01/11/2026
Week of Class (1-8): ONE
Body System focus area: Fundamentals
Case Study: A 42-year-old female complains of progressive weight gain of 20 pounds over the last
year, fatigue, postural dizziness, loss of memory, slow speech, deepening of her voice, dry skin,
constipation, and cold intolerance. She claims her menses have been irregular x 1 year. She has an 18-
year-old daughter and has been attempting to have another child with her new partner. She has been
unsuccessful.
Note: Include in-text citations as needed (author, year).
Questions (if data is unavailable, indicate “unavailable”):
1. What is the client’s chief complaint?
In one year a 20-pound weight gain, patient is a middle-aged female (42), deepening of voice,
irregular menses and possible infertility, dry skin, constipation, cold tolerance, fatigue,
postural dizziness, loss of memory, and slow speech.
2. What questions would you ask the client?
HPI (History of present illness)- How are your periods? Are they light or heavy? How are your
cramps and other symptoms when you have your period? How irregular are your periods, are
they ever 40 days, 20 days, do you miss your period completely without being pregnant? How
many months have you been trying to get pregnant for? Did you have any issues with getting
pregnant with your 18-year-old daughter?
ROS (Review of systems)- I would tell the patient I would like to do a head-to-toe assessment.
During the assessment I would check the patient’s thyroid. Is the thyroid tender when
swallowing, is it center on the throat. I would look at the presentation of the eyes. Are the eyes
sunk in or bulging. I would check the patient’s skin looking at the integrity, if she is having more
hair growth in places she has not before. I would check the patient’s neck looking for hunch
back. I would also want to do some balance and gait tests to see if she passes. Lastly, I would
send her to lab to collect a TSH, Free T4, CBC. Depending on the labs I would follow up with Anti-
TPO antibodies test and pituitary function test.
Medical, Surgical, Psych History- Does the patient suffer with mental health disorders like
depression or bipolar. Has the patient had and recent trauma like death in the family or a friend.
What does the patients support system look like. Has the patient had surgery. If so, has she had
