dixie. . .first off let me give you the definitions of subjective and objective data.
objective data is information that you can perceive using your owns senses. you can see, hear, smell, feel, sometimes taste, and sometimes measure objective data.
subjective data is information supplied to you by the subject, or patient
. they are things that you cannot yourself perceive with your senses of sight, sound, smell, or touch. for example, pain. a patient tells you they have a pain in their leg. that is subjective data. it is based on the patient's statement. you cannot see, hear, smell, or feel the patient's pain. however, you can see a grimace on the face of someone in pain. the grimace on their face would be an objective observation.
to get back to what you posted, you kind of have the two mixed up. anything the patient says and is surrounded by quotation marks in a case study should be taken as being subjective data. where your case study says, "he is observed to need assistance", you are being told that the observer actually viewed that, so it should be taken as objective data.
yes, past medical history is included in a case history. is is part of the review of symptoms. a review of symptoms is done before a physical exam.
when you are doing case studies, it is helpful to look at a medical resource that can give you the signs and symptoms of any diseases that might be mentioned that the patient in the case study has. otherwise, you just have to work with the information that you are given. you should have in your mind what is generally assessed during a physical exam and nursing assessment
. besides doing a physical examination, nurses also assess a patient's ability to perform activities of daily living (adls). so, your patient in this case study who was observed to need assistance was assessed by someone with regard to his abilities to perform adls. i hope you were given a little more information than that, however, if you are to develop something more complex like a plan of care from that information.
here are some links to case studies that were done by students on actual patients. might give you some ideas of how case studies are organized and put together.
here is a link to head to toe assessment in 5 minutes, a great guide to physical assessment of the patient
this page has a link you can click on, "write ups" where you can see two examples of what a phycians's history and physical exam look like in the sequence they should be written. nursing exams of patient follow a similar sequence.