Nursing

NURS_6512_M3AS2_Assignment_Template.docx

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.

SimulationcasestudyModul3.docx

Simulation Case Studies -Burning In Chest After Eating

Burning in Chest After Eating Presentation

Angela Brooks

Age: 52 Sex: Female Race/Ethnicity: African American Marital Status: Divorced Occupation: Real Estate Agent Insurance: Private Living Situation: Lives alone

Chief Complaint (CC): Burning in Chest After Eating

Patient Statement

For about the past three or four months, I’ve been getting this burning feeling in the middle of my chest after I eat. It usually starts about 30 minutes to an hour after meals, especially if I eat something spicy or fried. Sometimes it feels like the food is coming back up into my throat, and I get a sour taste in my mouth.

It’s not really a sharp pain — more like a burning pressure. I’d rate it about a 5 out of 10. It’s worse when I lie down at night, and I’ve had to prop myself up on pillows. I’ve also noticed I clear my throat a lot in the mornings.

I haven’t had shortness of breath. No sweating. No pain going into my arm or jaw. I haven’t thrown up, and I haven’t seen any blood. My weight has been stable.

I drink coffee every morning and usually have a glass of wine a few nights a week. I’ve been under some stress lately and probably eat out more than I should. I’ve been taking over-the-counter antacids, and they help, but the symptoms keep coming back.

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NURS_6512_Assessment_ReferenceSheet.pdf

NURS 6512: Assessment Reference Sheet Purpose To guide you in writing a clear, logical Assessment, including differential diagnoses, one final diagnosis supported by evidence, and required references supporting clinical reasoning.

Overview of Expectations - Include 3–5 differential diagnoses.

- Select ONE final diagnosis.

- Support all reasoning with subjective and objective findings.

- Use professional, concise clinical language.

- Include 3–5 peer-reviewed references (≤5 years old) to support diagnostic reasoning.

Differential Diagnoses (3–5 Required) Differential #1 Condition:

Rationale:

Subjective findings (supporting):

-

Subjective findings (non-supporting/absent):

-

Objective findings (supporting):

-

Objective findings (non-supporting/absent):

-

Differential #2 Condition:

Rationale:

Subjective findings (supporting):

-

Subjective findings (non-supporting/absent):

-

Objective findings (supporting):

-

Objective findings (non-supporting/absent):

-

Differential #3 Condition:

Rationale:

Subjective findings (supporting):

-

Subjective findings (non-supporting/absent):

-

Objective findings (supporting):

-

Objective findings (non-supporting/absent):

-

Differential #4 (Optional)

Differential #5 (Optional)

Final Diagnosis (ONE ONLY) Final Diagnosis: [Write the final diagnosis here]

Final Problem Statement Template [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].

Reference Requirements You must include 3–5 peer-reviewed journal references (published within the last 5 years) to support diagnostic reasoning in the Assessment. References must: - Align with the differential diagnoses and/or final diagnosis.

- Support pathophysiology, clinical presentation, or diagnostic criteria. - Be cited in APA 7th edition format. - Not include textbooks, blogs, or patient-education websites. Example acceptable sources: - Peer-reviewed journal articles - Clinical practice guidelines (ACC/AHA, ADA, IDSA, AAP, USPSTF) - Systematic reviews or meta-analyses

NURS_6512_PhysicalExamination_ReferenceSheet.pdf

NURS 6512: Physical Examination Reference Sheet NURS 6512 – Advanced Health Assessment & Diagnostic Reasoning

Purpose: To guide students in documenting objective findings only during the physical examination.

REMINDER: PHYSICAL EXAM = OBJECTIVE DATA ONLY This section should include only what you observe, measure, or assess — not what the patient reports. Do NOT include subjective statements or history.

✅ Correct (Objective): “Lungs clear to auscultation bilaterally; no wheezes, rales, or rhonchi.”

❌ Incorrect (Subjective): “Patient reports shortness of breath and chest tightness.”

GENERAL FORMAT FOR PHYSICAL EXAM DOCUMENTATION • General: Appearance, distress, hygiene, orientation • Skin: Color, temperature, turgor, lesions, rashes • Head: Normocephalic, atraumatic • Eyes: PERRLA, EOMI, conjunctiva clear • Ears: TM intact, no erythema or effusion • Nose: Mucosa pink, septum midline, no discharge • Mouth/Throat: Mucosa moist, no erythema or exudate • Neck: Supple, no lymphadenopathy, thyroid non-enlarged • Cardiac: RRR, no murmurs, rubs, or gallops • Lungs: CTA bilaterally, no wheezes, rales, or rhonchi • Abdomen: Contour, bowel sounds, tenderness, organomegaly • GU: External genitalia, discharge, lesions, CVA tenderness (as indicated) • Musculoskeletal: ROM, strength, gait, deformities, tenderness • Lower Extremities: Edema, pulses, color, warmth, capillary refill, sensation • Neuro: CN II–XII grossly intact, strength and sensation symmetrical

Chief Complaint, Must-Not-Miss Diagnoses, and Systems to Examine Identify high-priority conditions and focus your exam to rule them out.

Chief Complaint Must-Not-Miss Diagnoses Systems to Examine

Cough or Shortness of Breath

Pneumonia, Pulmonary embolism, Myocardial infarction, Heart failure, Pneumothorax

Respiratory, Cardiac, ENT, Skin (cyanosis), Lower Extremities (edema/DVT signs)

Abdominal Pain Appendicitis, Bowel obstruction, Perforated

Abdomen, GU, Cardiac, Respiratory, Skin

ulcer, Ectopic pregnancy, Cholecystitis, Pancreatitis

(jaundice), Neuro (pain localization)

Headache Subarachnoid hemorrhage, Meningitis, Temporal arteritis, Intracranial mass, Hypertensive emergency, CVA (stroke)

Neuro, HEENT, Neck, Eyes (fundoscopic), Cardiac (BP), Skin (rash/meningitis)

Back Pain Cauda equina syndrome, Epidural abscess, Spinal fracture, Pyelonephritis, Abdominal aortic aneurysm (AAA)

Musculoskeletal, Neuro, Abdomen, GU (CVA tenderness), Skin (infection)

UTI Symptoms Pyelonephritis, Urosepsis, Pregnancy, Obstructive uropathy

Abdomen, GU, CVA tenderness, Skin (fever signs), Neuro (confusion in elderly)

Sore Throat Peritonsillar abscess, Epiglottitis, Mononucleosis, Streptococcal pharyngitis

HEENT, Lymphatic, Neck, Cardiac, Respiratory (airway), Skin (rash/scarlatina)

Rash Cellulitis, Meningococcemia, Stevens-Johnson syndrome, Drug reaction, Anaphylaxis

Skin, Lymphatic, HEENT (mucosal lesions), Respiratory (distress), Cardiac (shock signs)

Extremity/Joint Pain DVT, Septic joint, Fracture, Cellulitis, Compartment syndrome

Musculoskeletal, Neuro, Lower Extremities (pulses, edema, warmth, sensation), Skin

DOCUMENTATION TIP • Use head-to-toe format only for comprehensive exams (annuals, new patient, baseline). • Use focused format for problem-based visits. • Objective findings should align with your assessment and must-not-miss differential diagnoses.

NURS_6512_ComprehensiveHealthHistory_ReferenceSheet1.pdf

NURS 6512: Comprehensive Health History Reference Sheet

⚠ Reminder: The health history includes **subjective data only** — information provided by the patient about their symptoms, perceptions, and experiences. Objective findings belong in the physical exam section.

Chief Complaint (CC)

• State the patient’s main reason for visit — concise and focused. • Use the patient’s own words in quotes (1–2 words or one short sentence). • Example: “Sore throat for two days.” or “Shortness of breath.”

History of Present Illness (HPI) – OLDCARTS + Pertinent History

• Use OLDCARTS to gather data, then synthesize into a cohesive paragraph written in complete sentences. • Avoid bullet points. Tell the story of the symptom(s) using the data you collected. • O – Onset: When did it start? • L – Location: Where is it? Does it radiate? • D – Duration: Constant or intermittent? • C – Character: Describe the quality (sharp, dull, throbbing). • A – Aggravating factors: What makes it worse? • R – Relieving factors: What makes it better? • T – Timing: Pattern, frequency, time of day. • S – Severity: 0–10 pain scale or functional impact. • Include associated symptoms and pertinent negatives (important symptoms the patient denies). • Incorporate pertinent history such as recent illness, exposures, travel, medications tried, previous episodes, or related chronic conditions. • Example: The HPI should read as a full paragraph that flows logically and reflects critical thinking — not as a list of OLDCARTS items.

Past Medical History (PMH)

• Chronic illnesses (HTN, DM, asthma, etc.) • Childhood illnesses (if relevant) • Hospitalizations and psychiatric history

Surgical History (PSH)

• List all surgeries/procedures with year, indication, and complications

Medications

• List all: prescription, OTC, herbal, and supplements • Include name, dose, route, frequency, indication • Note adherence and side effects

Allergies

• Drug, food, environmental — include reaction type (rash, anaphylaxis, etc.) • Document tolerated alternatives if known

Preventive Health

• Immunizations: Flu, COVID-19, Tdap, shingles, pneumococcal • Screenings: Pap, mammogram, colonoscopy, lipid, glucose, DEXA • Risk factors: Diet, exercise, safety, sexual health, sleep, stress, dental, vision

Social History

• Tobacco: Type, amount, duration, quit attempts • Alcohol: Type, frequency, quantity (CAGE if indicated) • Substance use: Illicit or prescription misuse • Occupation: Exposures, stress, satisfaction • Living situation & support system • Safety: IPV, firearms, seatbelt use • Social Determinants of Health (SDOH): Housing, food, transport, access, finances

Review of Systems (ROS)

These are subjective symptoms that the patient reports. No objective exam findings should be included here.

• General: Fever, chills, weight change, fatigue • Skin: Rashes, lesions, itching • HEENT: Vision, hearing, congestion, sore throat • Cardiac: Chest pain, palpitations, edema • Respiratory: Cough, SOB, wheezing • GI: N/V/D, constipation, pain, appetite • GU: Dysuria, frequency, hematuria • MSK: Joint pain, stiffness, weakness • Neuro: Headache, dizziness, numbness, seizures • Psych: Mood, anxiety, sleep • Endo: Heat/cold intolerance, polyuria/polydipsia • Heme: Easy bruising/bleeding