week 7 case study

NURS 6512

Week 7 Assignment Template

Comprehensive Health History, Physical Examination, and Assessment Template

Part I: Comprehensive Health History (Subjective Data Only)

Subjective Data

Chief Complaint (CC):

History of Present Illness (HPI):

Past Medical History (PMH):

Surgical History (PSH):

Medications:

Allergies:

Preventive Health:

Social History:

Review of Systems (ROS) (Subjective Data Only – Patient-Reported Symptoms):

General:

Skin:

HEENT:

Cardiac:

Respiratory:

Gastrointestinal (GI):

Genitourinary (GU):

Musculoskeletal (MSK):

Neurologic:

Psychiatric:

Endocrine:

Hematologic/Lymphatic/Immune:

Part II: Focused Physical Examination (Objective Data Only)

Physical Examination: Objective Data Only (Do NOT include subjective statements):

General:

Skin:

Head:

Eyes:

Ears:

Nose:

Mouth/Throat:

Neck:

Cardiac:

Lungs:

Abdomen:

Genitourinary (GU):

Musculoskeletal:

Lower Extremities:

Neurologic:

Part III: Assessment and Diagnostic Reasoning

Part III, Section 1: Three Differential Diagnoses

Directions: Using the template below, for each differential diagnosis, provide pathophysiologic explanation, identify pertinent positives, identify pertinent negatives, explain why it is ruled in or ruled out.

Differential Diagnosis #1:

Condition:

Rationale:

Pertinent positives and negatives:

Differential Diagnosis #2:

Condition:

Rationale:

Pertinent positives and negatives:

Differential Diagnosis #3:

Condition:

Rationale:

Pertinent positives and negatives:

Part III, Section 2: One Primary Diagnosis

Directions: Indicate your final diagnosis ( ONE ONLY). Include your diagnostic reasoning with rationale: provide clear clinical justification, correlate subjective and objective findings, and explain why competing diagnoses are less likely.

Part III, Section 3: Final Problem Statement

Directions: Use the template below to write a final, synthesized problem statement.

[Initials/Name], [Age], presents with [chief complaint] characterized by [positive subjective findings] and denies [negative subjective findings]. Physical exam reveals [positive objective findings] with absence of [negative objective findings]. Pertinent history includes [relevant PMH, family history, or risk factors]. The overall clinical picture is most consistent with [final diagnosis].

Part IV: Reflection

This reflection is designed to strengthen your clinical reasoning and your ability to clearly separate subjective and objective data in documentation.

Part IV, Section 1: Subjective vs. Objective Distinction

1. Identify one example in your documentation where it was challenging to separate subjective and objective data.

2. Explain how you ensured patient-reported symptoms remained in the history/ROS and observable findings remained in the physical exam.

3. Briefly explain why this distinction is important for diagnostic accuracy.

Part IV, Section 2: Diagnostic Reasoning

1. Identify one differential diagnosis you strongly considered but ultimately ruled out.

2. List two key findings (pertinent positives or negatives) that helped you rule it out.

3. State what finding most strongly supported your final diagnosis.

References

List 3–5 peer-reviewed references, less than 5 Years Old. Cite all sources in APA format.