University Academic Integrity Policy

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University Policy 3.01.01 Academic
Integrity and Honesty
Policy Revision Approval Date: March 23, 2014
Policy Revision Effective Date: April 1, 2014
Procedure Approval Date: November 30, 2020
Procedure Effective Date: December 1, 2020
POLICY STATEMENT
Capella University is committed to providing learners with the
competencies and skills
associated with academic integrity and honesty. Capella
learners are expected to act with
integrity and honesty in all their interactions as associated with
their academic endeavors
pursuant to this policy. Academic dishonesty occurs when
learners take unauthorized actions in
the completion of their academic work and may include but is
not limited to plagiarism,
unauthorized collaboration, deceit, and interference with
another learner.
Learners are expected to be the sole authors of their work and to
acknowledge the authorship of
others’ work through proper citation and reference. Use of
another person’s ideas, including
another learner’s, without proper reference or citation
constitutes plagiarism and academic
dishonesty and is prohibited conduct. Capella extends the

concept of plagiarism to include
issues of copyright and trademark infringement.
Collaboration in the completion of coursework is prohibited
unless explicitly permitted by the
course instructor. Where such collaboration is permitted by the
course instructor, learners must
acknowledge any collaboration and its extent in all submitted
coursework.
The consequences of academic dishonesty are determined on a
case-by-case basis may include
but are not limited to non-acceptance of submitted coursework,
failing grade on an assignment,
lower grade in a course, failing grade in a course, written
warning, suspension from the
university, removal from the program, administrative
withdrawal or dismissal from the
university, or cancellation of previously awarded course credits
or degrees. Cancellation of
previously awarded degrees require the review and
determination by the Capella University
Board of Trustees.
Capella University learners, faculty, and staff share the
responsibility for promptly reporting any
alleged violation of this policy.
RATIONALE
In support of Capella University’s core values, this policy
establishes the standards for academic
integrity and enforces the university’s commitment to teaching
and learning while maintaining
academic integrity, authenticity, ethics, and scholarship in one’s
work as a learner at the

university. This policy also establishes the due process
procedures for the internal resolution of
acts of academic dishonesty.
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DEFINITIONS
Plagiarism
Plagiarism is presenting someone else’s ideas or work as one’s
own. Plagiarism also includes
copying verbatim or rephrasing ideas without properly
acknowledging the source by author, date,
and publication medium. Learners must take great care,
whether in a draft or final version of a
paper or project, to distinguish their own ideas and language
from information acquired from
other sources. Sources include published primary and
secondary materials, electronic media,
unpublished materials, and information and ideas gained
through other people.
Sanction
A sanction is a disciplinary consequence that may be issued by
faculty or the university due to a
learner committing an act of academic dishonesty.
PROCEDURES
I. Academic Resources
The Publication Manual of the American Psychological

Association (APA) is a required
tool to help learners identify work that must be referenced,
including their own published
works, and determine how it must be cited. To avoid any
instances that may be construed
as plagiarism, learners should consult the APA style guide to
apply the proper citation
format. However, where this policy and the APA style guide
diverge, this policy will take
precedence.
II. Application to Doctoral Learners
A. This policy and procedure applies to all allegations of
plagiarism involving doctoral
learners and dissertation or doctoral capstones prior to receipt
of IRB approval or “not
human subjects research” designation letter from the Capella
University IRB.
B. All allegations of plagiarism involving a dissertation or
doctoral capstone after receipt
of IRB approval or “not human subjects research” designation
letter will be processed
according to the provisions in university policy 3.03.06
Research Misconduct.
III. Reporting Allegations of Academic Dishonesty
A. Anyone may report an allegation of academic dishonesty.
B. The allegation should be reported verbally or in writing to
the faculty member or
university official responsible for supervising the course or

activity during which the
allegation occurred.
C. The individual receiving the report of the allegation will
bring it to the attention of the
faculty member or university official directly associated with
the course or activity
during which the alleged academic dishonesty occurred, should
the report be made to
someone other than this faculty member or university official.
IV. Resolution of Allegations of Academic Dishonesty
The faculty member or university official directly associated
with the course or activity
during which the alleged academic dishonesty occurred will
contact the learner to notify
him or her of the alleged academic dishonesty. The learner will
be given the opportunity to
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explain or refute the allegation. Documentation of the alleged
academic dishonesty and
any issued sanctions will become part of the learner’s official
academic record.
A. If the faculty member or university official determines that
the allegation was
accurately identified as academic dishonesty, the faculty
member or university official
may offer the learner an opportunity to demonstrate academic
integrity, conduct

teaching/learning experiences to improve academic integrity
competencies and skills,
and/or issue another sanction appropriate to the course or
activity.
B. A record of the reporting individual’s or university official’s
sanction will become part
of the learner’s official academic record.
V. Academic Dishonesty Sanctions
A. A single instance of academic dishonesty may result in
severe sanctions, depending on
the offense. Multiple instances of academic dishonesty may
result in more severe
sanctions.
B. A failing course grade sanction can be issued during or after
a learner’s participation in
a course. A learner who receives a failing grade as a sanction
for a course is prohibited
from dropping or withdrawing from that course.
C. The university may refer allegations of academic dishonesty
to a university designee
to review the evidence associated with the allegation in
conjunction with the
learner’s complete academic integrity history.
1. If the university designee confirms or issues a sanction, the
sanctioned learner
will be notified in writing of the decision.
2. The university designee may refer allegations of academic
dishonesty to an

independent review panel.
D. Learners have the right to appeal faculty-, university
official-, or university designee-
issued sanctions to an independent review panel.
VI. Review by Independent Review Panel
A. An independent review panel may be convened at the
university’s discretion or due to a
learner appeal of a faculty-, university official-, or university
designee-issued sanction.
B. An independent review panel is sponsored by the provost.
C. A learner must submit their appeal within 30 calendar days
after notification of the
decision for which the learner is making the appeal has been
sent. The appeal request
must include a request for review of the allegation and must
provide evidence that a
violation of this policy did not occur or that administered
sanctions were inappropriate.
VII. Independent Review Panel Review Process
A. Upon being convened, the university will acknowledge the
request and inform all
involved parties that a review has been initiated.
B. All involved parties will be given the opportunity to submit
written statements and
other evidence supporting their respective positions.
C. All involved parties will be given the opportunity to present
their respective positions to

the panel.
D. The panel will review the evidence associated with the
academic dishonesty allegation;
any sanction already issued by faculty, a university official, or a
university designee;
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and any statements made by an involved party. The panel will
issue a decision as soon
as practicable.
E. The panel may conduct a full review of the learner, including
their complete history of
academic integrity. In the event the panel identifies additional
alleged instances of
academic dishonesty, the panel will notify the learner and
provide an opportunity to
respond.
F. The panel maintains the right to issue an appropriate
sanction. The panel’s sanction
may be more or less severe than any prior sanction issued to the
learner.
G. If the panel recommends the cancellation of previously
awarded credits or degrees, the
matter will be referred to the provost or president’s designee for
determination.
H. In the event that the provost or president’s designee believes
that a degree conferred by

Capella should be revoked as a result of an academic dishonesty
finding, the Capella
University Board of Directors must review the case and vote
whether to revoke the
degree. The respondent will receive written notification of the
final determination and
any corrective/disciplinary action to be taken.
I. Both parties have the right to appeal the panel’s decision
pursuant to procedure VII.
VIII. Appeal Process
A. A written appeal request must be submitted to the president’s
designee via certified
mail or email within 10 calendar days of notification of the
panel’s decision being sent.
B. Upon receipt of the appeal request, the president’s designee
will acknowledge the
request and inform all involved parties that an appeal has been
initiated.
C. The president’s designee will review all prior evidence,
records, and faculty and panel
decisions associated with the academic dishonesty allegation.
The president’s designee
may direct the panel to provide additional information.
D. Following review, the president’s designee will issue a
decision and report it to all
involved individuals as soon as practicable. The decision may
uphold the panel’s
decision, reverse the panel’s decision, or alter the panel’s
decision.

E. The decision of the president’s designee is final. Matters
that have been reviewed and
have received a final decision under this policy are not eligible
for further review under
another policy.
IX. Recording a Final Decision
A record of any final decision and all related materials will
become part of the learner’s
official academic record and upon request will be made
available to all Capella boards and
any appropriate regulatory bodies.
X. Copyright
A. Faculty, staff, and learners must comply with federal
copyright and trademark laws,
such as the Digital Millennium Copyright Act.
B. No one may use Capella information resources and other
information technology tools
for unauthorized file sharing, posting of copyrighted materials
as one’s own, or other
copyright violations.
C. In addition to Capella University sanctions, under The
Digital Millennium Copyright
Act, copyright infringement can result in civil and criminal
liabilities for unauthorized
distribution of copyrighted materials including but not limited
to the following:

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1. Payment of money to the copyright holder in a lawsuit—
between $750 and $30,000
for each file, and up to $150,000 for each file if the
infringement was willful.
2. Payment of copyright holder’s costs and attorney fees to
bring the lawsuit.
3. Payment of criminal fines up to $250,000, and up to 10 years
jail time.
4. Seizure and destruction of infringing files.
XI. All procedures in this policy apply to learners in
GuidedPath and FlexPath programs.
POLICY OWNERS
Academic Owner: Provost
Operations Owner: Office of Academic Community Standards
RELATED DOCUMENTS
University policy 1.01.05 Policy Exceptions
University policy 2.02.10 Separation from the University
University policy 3.03.02 Publication of Dissertations and
Doctoral Capstones
University policy 3.03.06 Research Misconduct
University policy 4.02.02 Learner Code of Conduct
University policy 4.02.03 Learner Grievance
REVISION HISTORY
Original Policy Approval Date: July 27, 2002

Revision Dates: 1-1-05; 8-28-07; 7-29-09; 8-12-11; 8-20-12; 3-
23-14; 7-28-14; 8-11-16; 3-30-
17; 10-31-17; 3-31-20; 11-30-20
Administrative edits as result of ongoing review: 12-20-07; 2-
19-10; 4-17-12; 4-24-13; 11-1-16;
12-14-16; 4-1-18; 10-15-18; 5-23-19; 7-1-20; 3-26-21
University Policy 3.01.01 Academic
Integrity and HonestyPOLICY
STATEMENTRATIONALEDEFINITIONSPROCEDURESPOLI
CY OWNERSRELATED DOCUMENTSREVISION HISTORY
Name:
Section:
Week 7
Shadow Health Digital Clinical Experience Focused Exam:
Chest Pain Documentation
SUBJECTIVE DATA: Include what the patient tells you, but
organize the information.
Chief Complaint (CC): In just a few words, explain why the
patient came to the clinic.
History of Present Illness (HPI): This is the symptom analysis
section of your note. Thorough documentation in this section is
essential for patient care, coding, and billing analysis. Paint a
picture of what is wrong with the patient. You need to start
EVERY HPI with age, race, and gender (i.e. 34-year-old AA
male). You must include the 7 attributes of each principal
symptom:
1. Location
2. Quality
3. Quantity or severity

4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations
Medications: Include over the counter, vitamin, and herbal
supplements. List each one by name with dosage and frequency.
Allergies: Include specific reactions to medications, foods,
insects, and environmental factors.
Past Medical History (PMH): Include illnesses (also childhood
illnesses), hospitalizations, and risky sexual behaviors.
Past Surgical History (PSH): Include dates, indications, and
types of operations.
Sexual/Reproductive History: If applicable, include obstetric
history, menstrual history, methods of contraception, and sexual
function.
Personal/Social History: Include tobacco use, alcohol use, drug
use, patient’s interests, ADL’s and IADL’s if applicable, and
exercise and eating habits.
Immunization History: Include last Tdp, Flu, pneumonia, etc.
Significant Family History: Include history of parents,
Grandparents, siblings, and children.
Review of Systems: From head-to-toe, include each system that
covers the Chief Complaint, History of Present Illness, and
History).Remember that the information you include in this
section is based on what the patient tells you. You will only
need to cover systems pertinent to your CC, HPI (N/A,

UNKNOWN is not acceptable, make up the information if you
need to). To ensure that you include all essentials in your case,
refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue,
or fever, but do not restate HPI data here.
Cardiovascular/Peripheral Vascular:
Respiratory:
Gastrointestinal:
Musculoskeletal:
Psychiatric:
OBJECTIVE DATA: From head-to-toe, includewhat you see,
hear, and feel when doing your physical exam. You only need to
examine the systems that are pertinent to the CC, HPI, and
History unless you are doing a total H&P. Do not use WNL or
normal. You must describe what you see.
Physical Exam:
Vital signs: Include vital signs, ht, wt, temperature, and BMI
and pulse oximetry.
General: Include general state of health, posture, motor activity,
and gait. This may also include dress, grooming, hygiene, odors
of body or breath, facial expression, manner, level of
conscience, and affect and reactions to people and things.
Cardiovascular/Peripheral Vascular: Always include
the heart in your PE.
Respiratory: Always include this in your PE.
Gastrointestinal:
Musculoskeletal:
Neurological:
Skin:
Diagnostic Test/Labs: Include any labs, x-rays, or other
diagnostics that are needed to develop the differential diagnoses

with rationale for each one documented OR ones that were
mentioned during the SH assignment.
ASSESSMENT: List your priority diagnosis(es). For each
priority diagnosis, list at least 3 differential diagnoses, each of
which must be supported with evidence and guidelines. For
holistic care, you need to include previous diagnoses and
indicate whether these are controlled or not controlled.
© 2021 Walden University
Rubric Detail
Select Grid View or List View to change the rubric's layout.
Content
Name: NURS_6512_Week_7_DCE_Assignment_1_Rubric
Description: To complete the Shadow Health assignments, it is
helpful to use the text and follow along with each chapter
correlating to the area of assessment to assist in covering all the
subjective questions and the physical assessment areas. Review
the Advanced Health Assessment Nursing Documentation
Tutorial located in the Weeks 1 and 4 Resources, the model
documentation in Shadow Health, as well as sample
documentation in the text to assist with narrative documentation
of the assessments.
Shadow Health exams may be added to or repeated as many
times as necessary prior to the due date to assist in achieving
the desired score.
Grid ViewList View

Excellent
Good
Fair
Poor
Student DCE score
(DCE percentages will be calculated automatically by Shadow
Health after the assignment is completed.)
Note: DCE Score - Do not round up on the DCE score.
Points:
Points Range:
56 (56%) - 60 (60%)

DCE score>93
Feedback:
Points:
Points Range:
51 (51%) - 55 (55%)
DCE Score 86-92

Feedback:
Points:
Points Range:
46 (46%) - 50 (50%)
DCE Score 80-85

Feedback:
Points:
Points Range:
0 (0%) - 45 (45%)
DCE Score <79
No DCE completed.

Feedback:
Subjective Documentation in Provider Notes
Subjective narrative documentation in Provider Notes is
detailed and organized and includes:
Chief Complaint (CC), HPI, Current Medications, Allergies,
Past Medical History, Family History, Social History and
Review of Systems (ROS)
ROS: covers all body systems that may help you formulate a list
of differential diagnoses. You should list each system as
follows:
General: Head: EENT: etc.
You should list these in bullet format and document the systems
in order from head to toe.
Points:

Points Range:
16 (16%) - 20 (20%)
Documentation is detailed and organized with all pertinent
information noted in professional language.
Documentation includes all pertinent documentation to include
Review of Systems (ROS).
Feedback:

Points:
Points Range:
11 (11%) - 15 (15%)
Documentation with sufficient details, some organization and
some pertinent information noted in professional language.
Documentation provides some of the Chief Complaint (CC),
HPI, Current Medications, Allergies, Past Medical History,
Family History, Social History and Review of Systems (ROS).
Feedback:

Points:
Points Range:
6 (6%) - 10 (10%)
Documentation with inadequate details and/or organization;
and inadequate pertinent information noted in professional
language.
Limited or/minimum documentation provided to analyze
students critical thinking abilities for the Chief Complaint (CC),
Feedback:

Points:
Points Range:
0 (0%) - 5 (5%)
Documentation lacks any details and/or organization; and does
not provide pertinent information noted in professional
language.
No information is provided for the Chief Complaint (CC), HPI,
Current Medications, Allergies, Past Medical History, Family
History, Social History and Review of Systems (ROS).
or

No documentation provided.
Feedback:
Objective Documentation in Provider Notes - this is to be
completed in Shadow Health
Physical exam: Document in a systematic order starting from
head-to-toe, include what you see, hear, and feel when doing
your physical exam using medical terminology/jargon.
Document all normal and abnormal exam findings. Do not use
"WNL" or "normal".
You only need to examine the systems that are pertinent to the
CC, HPI, and History.
Diagnostic result - Include any pertinent labs, x-rays, or
diagnostic test that would be appropriate to support the
differential diagnoses mentioned
Differential Diagnoses (list a minimum of 3 differential
diagnoses). Your primary or presumptive diagnosis should be at
the top of the list (#1).

Points:
Points Range:
16 (16%) - 20 (20%)
Documentation detailed and organized with all abnormal and
pertinent normal assessment information described in
professional language.
Each system assessed is clearly documented with measurable
details of the exam.
Feedback:

Points:
Points Range:
11 (11%) - 15 (15%)
Documentation with sufficient details and some organization;
some abnormal and some normal assessment information
described in mostly professional language.
Each system assessed is somewhat clearly documented with
measurable details of the exam.
Feedback:

Points:
Points Range:
6 (6%) - 10 (10%)
inadequate identification of abnormal and pertinent normal
assessment information described; inadequate use of
Each system assessed is minimally or is not clearly documented
with measurable details of the exam.

Feedback:
Points:
Points Range:
0 (0%) - 5 (5%)
Documentation with no details and/or organization; no
identification of abnormal and pertinent normal assessment
information described; no use of professional language.
None of the systems are assessed, no documentation of details
of the exam.

or
Feedback:
Show Descriptions
Show Feedback
Student DCE score
(DCE percentages will be calculated automatically by Shadow
Health after the assignment is completed.)
Note: DCE Score - Do not round up on the DCE score.--
Levels of Achievement:

Excellent
56 (56%) - 60 (60%)
DCE score>93
Good
51 (51%) - 55 (55%)
DCE Score 86-92
Fair
46 (46%) - 50 (50%)
DCE Score 80-85
Poor
0 (0%) - 45 (45%)

DCE Score <79
No DCE completed.
Feedback:
Subjective Documentation in Provider Notes
Subjective narrative documentation in Provider Notes is
detailed and organized and includes:
Review of Systems (ROS)
ROS: covers all body systems that may help you formulate a list
of differential diagnoses. You should list each system as
follows:
General: Head: EENT: etc.
You should list these in bullet format and document the systems
in order from head to toe.--

Excellent
16 (16%) - 20 (20%)
Documentation is detailed and organized with all pertinent
information noted in professional language.
Documentation includes all pertinent documentation to include
Review of Systems (ROS).
Good
11 (11%) - 15 (15%)
Documentation with sufficient details, some organization and
some pertinent information noted in professional language.
Documentation provides some of the Chief Complaint (CC),
Fair
6 (6%) - 10 (10%)

Documentation with inadequate details and/or organization; and
inadequate pertinent information noted in professional
language.
Limited or/minimum documentati on provided to analyze
students critical thinking abilities for the Chief Complaint (CC),
Poor
0 (0%) - 5 (5%)
Documentation lacks any details and/or organization; and does
not provide pertinent information noted in professional
language.
No information is provided for the Chief Complaint (CC), HPI,
Current Medications, Allergies, Past Medical History, Family
History, Social History and Review of Systems (ROS).
or

Feedback:
Objective Documentation in Provider Notes - this is to be
completed in Shadow Health
Physical exam: Document in a systematic order starting from
head-to-toe, include what you see, hear, and feel when doing
your physical exam using medical terminology/jargon.
Document all normal and abnormal exam findings. Do not use
"WNL" or "normal".
You only need to examine the systems that are pertinent to the
CC, HPI, and History.
Diagnostic result - Include any pertinent labs, x-rays, or
diagnostic test that would be appropriate to support the
differential diagnoses mentioned
Differential Diagnoses (list a minimum of 3 differential
diagnoses). Your primary or presumptive diagnosis should be at
the top of the list (#1).--
Excellent
16 (16%) - 20 (20%)

Documentation detailed and organized with all abnormal and
pertinent normal assessment information described in
Each system assessed is clearly documented with measurable
details of the exam.
Good
11 (11%) - 15 (15%)
Documentation with sufficient details and some organizatio n;
some abnormal and some normal assessment information
described in mostly professional language.
Each system assessed is somewhat clearly documented with
measurable details of the exam.
Fair
6 (6%) - 10 (10%)
inadequate identification of abnormal and pertinent normal
assessment information described; inadequate use of

Each system assessed is minimally or is not clearly documented
with measurable details of the exam.
Poor
0 (0%) - 5 (5%)
Documentation with no details and/or organization; no
identification of abnormal and pertinent normal assessment
information described; no use of professional language.
None of the systems are assessed, no documentation of details
of the exam.
or
Feedback:

Total Points:
100
Name: NURS_6512_Week_7_DCE_Assignment_1_Rubric
Description: To complete the Shadow Health assignments, it is
helpful to use the text and follow along with each chapter
correlating to the area of assessment to assist in covering all the
subjective questions and the physical assessment areas. Review
the Advanced Health Assessment Nursing Documentation
Tutorial located in the Weeks 1 and 4 Resources, the model
documentation in Shadow Health, as well as sample
documentation in the text to assist with narrative documentation
of the assessments.
Shadow Health exams may be added to or repeated as many
times as necessary prior to the due date to assist in achieving
the desired score.
Document: Provider Notes
Student Documentation
Model Documentation
Subjective
Mr. Foster is 58 years old Caucasian male. Chief Complaint:
Patient stated, "I have been having some troubling chest pain in
my chest now and then for the past month". HPI: Mr. Foster
reported that the onset on the chest pain was a month ago, and it
lasted about few minutes. At first, he said, I first noticed it
earlier this month, I thought it might just be heartburn and it
passed after a couple of minutes". He said that he feels the pain

mostly in the middle of his chest over his heart. He said that the
chest pain happened three times in the past month. And she said
it usually goes away after about a couple of minutes. He said
that the does not radiate to any other part of his body. He said
that the pain usually starts when He is doing something
physical, especially when is doing yard work and the second
time. Also, when he takes stair ways at work due to broken
elevator. He rated the pain the pain 5 out of 0-10, The pain gets
better when he is rested and lying down. His last chest pain was
last week Friday evening when he was taking stairs at work. He
stated that the pain feels very tight and uncomfortable. This is
the first time he has seen a care provider about the pain. He said
it would be crazy if he has the pain at work, and it would be
distracting him a lot.
Confirmed Medications: Metoprolol 100 mg, 1 tab., PO, daily
for hypertension in the morning. Atorvastatin 20 mg, PO daily,
at 10 PM, for hyperlipidemia in the evening. Omega-3 fish oil
1200mg 1 cap, PO daily int morning. Tylenol or Motrin when
having headache
Diagnostic Test: reported EKG done before and stress, and both
were normal last all primary care doctors 3 month ago. He said
that he sees his primary Care Provider (PCP) every 6 months.
Allergies: Codeine. When he takes codeine, he experiences
nausea and vomiting.
PMHx: Hypertension-stage 2, diagnosed 1 year ago.
Hyperlipidemia, diagnosed 1 year ago No surgical history.
Immunization: Tdap 10/2014
Influenza vaccine is up to date.
Family history:
Father- Hypertension, hyperlipidemia, obesity, and deceased at
age 75 years of colon cancer

Mother- Type 2 diabetes, Hypertension, age 80 years old.
Brother- died of motor vehicle accident at 24 years.
Sister- Age 52, has Type 2 diabetes, Hypertension.
Maternal grandfather: Died at age 54 of heart attack.
Maternal grandmother: died of breast cancer at age 65 years.
Paternal grandmother: Died of pneumonia at age 78.
Paternal grandmother: Died at 85 of old age.
Son: 26 years old and healthy.
Daughter: Age 19, diagnosed of asthma.
ROS: General: Mr. Foster denied night sweat, fever, fatigue,
and no recent illness. Skin: No rashes, no lesions, and no
changes of the skin noted. No sore throat reported, no shortness
of breath, and no difficulty swallowing. Reported no change on
family history.
N/A
Objective
V/S: T=36.7C (98.1F), HR=104, RR=19, B/P=146/90,
Sa02=98%. Weight: 197 lbs. Height: 5'11"
Face inspected without no visible abnormal findings. JVD
inspected and was measured 3cm above the sternal angle. Chest
walls were symmetrical without visible abnormal findings.
Abdomen inspected, flat and symmetrical in all quadrants
without visible abnormal findings. Bilateral hands inspected;
the appearance revealed no visible abnormal findings. Lower
extremities inspected, including examining toenails, legs
bilaterally for edema and there is edema noted. Capillary refills
both finger nails and toe nails tested and was present less than 3
seconds and no visible abnormal findings noted. The right
carotid artery auscultated and bruit was present, left artery
auscultated and no bruit indicated. Heart sound auscultated and
S1, S2, and S3 sounds were noted around the mitral valve.
Breath sound auscultated and all sounds are present,
adventitious sounds noted around the posterior right and left
lower lobes, fine crackles heard. Abdominal aorta auscultated
and no bruit noted. Abdominal and lower extremity arteries
were auscultated and no bruit. Auscultated bowel sounds in all 4

quadrants are present. Liver and spleen auscultated without
friction rub noted. Carotid arteries palpated with thrill and +3
noted on the right carotid, left palpated and no thrill, +2 noted.
Palpated PMI is displaced laterally brisk and tapping and less
than 3 cm. Palpated brachial arteries no thrill+2. Palpated left
and right femoral pulse without thrill +2. No tenderness
reported upon light palpation of all four abdominal quadrants,
no masses, no abnormal findings noted. Palpable 1 cm on the
location of the liver below the right coastal margin was noted.
No palpable spleen, no palpable left and right kidneys upon
palpation, Skin turgor warm and no tenting noted. All four
quadrants of abdomen percussed and no areas of dullness noted.
spleen percussed and no abnormality noted. Liver percussed and
liver span 7 cm noted in the midclavicular line. EKG result
showed regular sinus rhythm and no ST-elevation or any
changes.
N/A
Assessment
Diagnosis: Angina pectoris Bilateral basal crackle Elevated high
blood pressure Hyperlipidemia Inactive lifestyle.
N/A
Plan
Doppler study of the pulse, Stress test for exercise EKG, Order
for nitroglycerin to manage symptoms, daily aspirin regimen,
educate patient to reduce salt intake, educate patient to monitor
the signs of worsening symptoms, educate patient to start
exercise to help control hyperlipidemia, seek immediate medical
attention if signs and symptoms worsen and follow up with your
doctor.
N/A

University Academic Integrity Policy

University Academic Integrity Policy

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