The document provides an assessment rubric for a nursing school assignment involving the differential diagnosis of a skin condition. The assignment requires students to:
1) Document one of the provided skin graphics using the SOAP note format, identifying the graphic and explaining its physical characteristics.
2) Formulate alternative diagnoses for the graphic and determine the most likely diagnosis, supported by evidence from current literature.
3) Follow appropriate writing standards and APA format.
The rubric evaluates students' work across these criteria on excellence, good, fair, and poor scales and provides feedback.
MET Participants and Collaboration 20.0 Thoroughly outlines al.docx
1. MET Participants and Collaboration
20.0
Thoroughly outlines all participants of a multidisciplinary
evaluation team, insightfully describing the roles each team
member holds. Expertly describes how MET team members can
effectively collaborate with student’s family and each other.
Background Information
25.0
Analysis expertly describes case study background information,
identifying areas of significance. A professional, summary of
additional information that could be gathered from informal
observations and formal curriculum-based assessments that
might be significant is provided.
Assessment Recommendations
25.0
Two ideal assessments, one formal and one informal, are
recommended for the student related to eligibility, program, or
placement decisions. At least one example uses developmentally
appropriate technology. Explanation for assessment
recommendations is professional and convincing.
Thesis Development and Purpose
7.0
Thesis or main claim is comprehensive. The essence of the
paper is contained within the thesis. Thesis statement makes the
purpose of the paper clear.
Argument Logic and Construction
8.0
Clear and convincing argument that presents a persuasive claim
in a distinctive and compelling manner. All sources are
authoritative and thoroughly support the claim.
Mechanics of Writing (includes spelling, punctuation, grammar,
language use)
5.0
Submission is virtually free of mechanical errors. Word choice
7. Chapter 08: Skin, Hair, and Nails
Key Points
This review discusses examination of the skin, hair, and nails.
Before the exam, gather the necessary equipment: a clear,
flexible centimeter ruler; flashlight with transilluminator;
handheld magnifying glass or dermatoscope; and Wood’s lamp.
To examine the skin,perform the following.
Use inspection and palpation to examine the skin. Make sure
you have adequate lighting, preferably with daylight.
During inspection, expose the skin completely. As you
finish inspecting each area, remember to redrape or cover the
patient for warmth and modesty.Inspect the skin in two
ways.First, perform a brief overall visual sweep of the entire
skin surface. This helps identify the distribution and extent of
any lesions, assess skin symmetry, detect differences among
body areas, and compare sun-exposed areas with areas that were
not exposed to the sun.Second, observe the skin as each part of
the body is examined.When evaluating the skin and mucous
membranes in each part of the body, note six characteristics.The
first characteristic is color, which can vary from dark brown to
light tan with pink or yellow overtones.The second
characteristic is uniformity. The skin should be uniform in color
overall with no localized areas of discoloration. However, the
skin may have sun-darkened areas as well as darker skin around
the knees and elbows.The third characteristic is thickness,
which varies over the body. The thinnest skin is on the eyelids.
The thickest is at areas of pressure or rubbing, such as the
elbows, soles, and palms.The fourth characteristic is symmetry.
Normally, the skin appears bilaterally symmetrical.The fifth
characteristic is hygiene, which may contribute to skin
condition.The final characteristic is the presence of any lesions,
8. which are any pathologic skin change or occurrence.During
inspection, also palpate the skin to determine five
characteristics.First, palpate to detect moisture. Minimal
perspiration or oiliness should be present. Even intertriginous
areas should display little dampness.Second, use the dorsal
surface of your hands to assess temperature. The skin may feel
cool to warm but should be bilaterally symmetrical.Third, check
the texture, which should be smooth, soft, and even. However,
roughness on exposed skin or areas of pressure may
occur.Finally, evaluate the last two characteristics, turgorand
mobility, by pinching up a small section of skin on the forearm
or sternum, releasing it, and watching for it to immediately
return to place.If a lesion is present, inspect and palpate it fully.
Remember: Not all lesions are cause for concern, but they
should all be examined.
First, describe its size (measured in centimeters in all
dimensions), shape, color, texture, elevation or depression, and
attachment at the base.
If the lesion has exudates, note their color, odor, amount,
and consistency.If there is more than one lesion, describe their
configuration as annular (or ring-shaped), arciform (or bow-
shaped), grouped, linear, or diffuse.Record the lesions’ location
and distribution, noting whether they appear generalized or
localized, affect a specific body region, form a pattern, and are
discrete or confluent.Use a light and magnifying glass to
determine the lesion’s subtle details, including color, elevation,
and borders.To see if fluid is present in a cyst or mass,
transilluminate it in a darkened room. A fluid-filled lesion
transilluminates with a red glow; a solid lesion does not.To
further identify a lesion, shines a Wood’s lamp on the area in a
darkened room. Look for the well-demarcated hypopigmentation
of vitiligo, the hyperpigmentation of café au lait spots, and the
yellow-green fluorescence that suggests fungal infection.
To examine the hair, perform the following.To assess the hair,
palpate its texture. Scalp hair may be coarse or fine and curly or
9. straight. It should be shiny, smooth, and resilient.During
palpation, also inspect the hair for three characteristics: color,
distribution, and quantity.Hair color ranges from very light
blond to black to gray.Hair distribution and quantity vary with
genetics. Hair commonly appears on the scalp, lower face, neck,
nares, ears, chest, axillae, back, shoulders, arms, legs, toes,
pubic area, and around the nipples.
To examine the nails, perform the following.Use inspection and
palpation to assess the nails. Ask yourself: Are the nails dirty,
bitten to the quick, or unkempt? Or are they clean, smooth, and
neat? The condition of the hair and nails provides clues to the
patient’s self-care, emotions, and social integration.Inspect the
nails for six characteristics: color, length, condition,
configuration, symmetry, and cleanliness.Although nail shape
and opacity can vary greatly, the nail bed color should be pink.
Pigment deposits may appear in the nail beds of dark-skinned
patients.The nail length and condition should be appropriate—
not bitten down to the quick. The nail edges should be smooth
and rounded, with no peeling or jagged, broken, or bitten nail
edges or cuticles.In configuration, the nail plate should appear
smooth and flat or slightly convex. It should have no ridges,
grooves, depressions, or pits.The nails should appear bilaterally
symmetrical.The nails should be clean,smooth, and
neat.Measure the nail-base angle by placing a ruler across the
nail and dorsal surface of the finger and checking the angle
formed by the proximal nail fold and nail plate.The nail-base
angle should measure 160 degrees.If the nail-base angle is 180
degrees or more, clubbing is present, which suggests a
cardiopulmonary or other disorder.Inspect and palpate the
proximal and lateral nail folds for redness, swelling, pain, and
exudate as well as warts, cysts, and tumors. Pain usually
accompanies ingrown nails and infections.Palpate the nail plate
for four characteristics: texture, firmness, thickness, and
adherence to the nail bed.The texture of the nail plate should be
hard and smooth.The nail base should be firm—not boggy.The
10. nail thickness should be uniform. Thickened nails may result
from tight-fitting shoes, chronic trauma, or a fungal infection.
Nail thinning may accompany a nail disease.The nail should
adhere to the nail bed when you gently squeeze the patient’s
nail between your thumb and fingerpad.
Week 4 Lab Assignment: Differential Diagnosis for Skin
Conditions
1:
2:
3.
4.
5.
�Note to Build: These images are still pending permissions so I
don’t have credit lines yet or approval.
Page 5 of 5
Rubric Detail
Select Grid View or List View to change the rubric's layout.
Content
Name: NURS_6512_Week_4_Assignment_1_Rubric
11. · Grid View
· List View
Excellent
Good
Fair
Poor
Using the SOAP (Subjective, Objective, Assessment, and Plan)
note format:
· Create documentation, following SOAP format, of your
assignment to choose one skin condition graphic (identify by
number in your Chief Complaint). · Use clinical terminologies
to explain the physical characteristics featured in the graphic.
Points:
Points Range: 30 (30%) - 35 (35%)
The response clearly, accurately, and thoroughly follows the
SOAP format to document one skin condition graphic and
accurately identifies the graphic by number in the Chief
Complaint. The response clearly and thoroughly explains all
physical characteristics featured in the graphic using accurate
terminologies.
Feedback:
Points:
Points Range: 24 (24%) - 29 (29%)
The response accurately follows the SOAP format to document
one skin condition graphic and accurately identifies the graphic
by number in the Chief Complaint. The response explains most
physical characteristics featured in the graphic using accurate
terminologies.
Feedback:
Points:
Points Range: 18 (18%) - 23 (23%)
The response follows the SOAP format, with vagueness and
12. some inaccuracy in documenting one skin condition graphic,
and accurately identifies the graphic by number in the Chief
Complaint. The response explains some physical characteristics
featured in the graphic using mostly accurate terminologies.
Feedback:
Points:
Points Range: 0 (0%) - 17 (17%)
The response inaccurately follows the SOAP format or is
missing documentation for one skin condition graphic and is
missing or inaccurately identifies the graphic by number in the
Chief Complaint. The response explains some or few physical
characteristics featured in the graphic using terminologies with
multiple inaccuracies.
Feedback:
· Formulate a different diagnosis of three to five possible
considerations for the skin graphic. · Determine which is
most likely to be the correct diagnosis, and explain your
reasoning using at least three different references from current
evidence-based literature.
Points:
Points Range: 45 (45%) - 50 (50%)
The response clearly, thoroughly, and accurately formulates a
different diagnosis of five possible considerations for the skin
graphic. The response determines the most likely correct
diagnosis with reasoning that is explained clearly, accurately,
and thoroughly using three or more different references from
current evidence-based literature.
Feedback:
Points:
Points Range: 39 (39%) - 44 (44%)
The response accurately formulates a different diagnosis of
three to five possible considerations for the skin graphic. The
response determines the most likely correct diagnosis with
13. reasoning that is explained accurately using at least three
different references from current evidence-based literature.
Feedback:
Points:
Points Range: 33 (33%) - 38 (38%)
The response vaguely or with some inaccuracy formulates a
different diagnosis of three possible considerations for the skin
graphic. The response determines the most likely correct
diagnosis with reasoning that is explained vaguely and with
some inaccuracy using three different references from current
evidence-based literature.
Feedback:
Points:
Points Range: 0 (0%) - 32 (32%)
The response formulates inaccurately, incompletely, or is
missing a different diagnosis of possible considerations for the
skin graphic, with two or fewer possible considerations
provided. The response vaguely, inaccurately, or incompletely
determines the most likely correct diagnosis with reasoning that
is missing or explained using two or fewer different references
from current evidence-based literature.
Feedback:
Written Expression and Formatting - Paragraph Development
and Organization:
Paragraphs make clear points that support well-developed ideas,
flow logically, and demonstrate continuity of ideas. Sentences
are carefully focused--neither long and rambling nor short and
lacking substance. A clear and comprehensive purpose
statement and introduction are provided that delineate all
required criteria.
Points:
Points Range: 5 (5%) - 5 (5%)
Paragraphs and sentences follow writing standards for flow,
14. continuity, and clarity. A clear and comprehensive purpose
statement, introduction, and conclusion are provided that
delineate all required criteria.
Feedback:
Points:
Points Range: 4 (4%) - 4 (4%)
Paragraphs and sentences follow writing standards for flow,
continuity, and clarity 80% of the time. Purpose, introduction,
and conclusion of the assignment are stated, yet are brief and
not descriptive.
Feedback:
Points:
Points Range: 3 (3%) - 3 (3%)
Paragraphs and sentences follow writing standards for flow,
continuity, and clarity 60%–79% of the time. Purpose,
introduction, and conclusion of the assignment are vague or off
topic.
Feedback:
Points:
Points Range: 0 (0%) - 2 (2%)
Paragraphs and sentences follow writing standards for flow,
continuity, and clarity < 60% of the time. No purpose statement,
introduction, or conclusion were provided.
Feedback:
Written Expression and Formatting - English writing standards:
Correct grammar, mechanics, and proper punctuation
Points:
Points Range: 5 (5%) - 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
Feedback:
Points:
Points Range: 4 (4%) - 4 (4%)
15. Contains a few (1 or 2) grammar, spelling, and punctuation
errors.
Feedback:
Points:
Points Range: 3 (3%) - 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation
errors.
Feedback:
Points:
Points Range: 0 (0%) - 2 (2%)
Contains many (≥ 5) grammar, spelling, and punctuation errors
that interfere with the reader’s understanding.
Feedback:
Written Expression and Formatting - The paper follows correct
APA format for title page, headings, font, spacing, margins,
indentations, page numbers, running heads, parenthetical/in-text
citations, and reference list.
Points:
Points Range: 5 (5%) - 5 (5%)
Uses correct APA format with no errors.
Feedback:
Points:
Points Range: 4 (4%) - 4 (4%)
Contains a few (1 or 2) APA format errors.
Feedback:
Points:
Points Range: 3 (3%) - 3 (3%)
Contains several (3 or 4) APA format errors.
Feedback:
Points:
16. Points Range: 0 (0%) - 2 (2%)
Contains many (≥ 5) APA format errors.
Feedback:
Show Descriptions Show Feedback
Using the SOAP (Subjective, Objective, Assessment, and Plan)
note format:
· Create documentation, following SOAP format, of your
assignment to choose one skin condition graphic (identify by
number in your Chief Complaint). · Use clinical terminologies
to explain the physical characteristics featured in the graphic.--
Levels of Achievement:
Excellent 30 (30%) - 35 (35%)
The response clearly, accurately, and thoroughly follows the
SOAP format to document one skin condition graphic and
accurately identifies the graphic by number in the Chief
Complaint. The response clearly and thoroughly explains all
physical characteristics featured in the graphic using accurate
terminologies.
Good 24 (24%) - 29 (29%)
The response accurately follows the SOAP format to document
one skin condition graphic and accurately identifies the graphic
by number in the Chief Complaint. The response explains most
physical characteristics featured in the graphic using accurate
terminologies.
Fair 18 (18%) - 23 (23%)
The response follows the SOAP format, with vagueness and
some inaccuracy in documenting one skin condition graphic,
and accurately identifies the graphic by number in the Chief
Complaint. The response explains some physical characteristics
featured in the graphic using mostly accurate terminologies.
Poor 0 (0%) - 17 (17%)
The response inaccurately follows the SOAP format or is
missing documentation for one skin condition graphic and is
missing or inaccurately identifies the graphic by number in the
Chief Complaint. The response explains some or few physical
17. characteristics featured in the graphic using terminologies with
multiple inaccuracies.
Feedback:
· Formulate a different diagnosis of three to five possible
considerations for the skin graphic. · Determine which is
most likely to be the correct diagnosis, and explain your
reasoning using at least three different references from current
evidence-based literature.--
Levels of Achievement:
Excellent 45 (45%) - 50 (50%)
The response clearly, thoroughly, and accurately formulates a
different diagnosis of five possible considerations for the skin
graphic. The response determines the most likely correct
diagnosis with reasoning that is explained clearly, accurately,
and thoroughly using three or more different references from
current evidence-based literature.
Good 39 (39%) - 44 (44%)
The response accurately formulates a different diagnosis of
three to five possible considerations for the skin graphic. The
response determines the most likely correct diagnosis with
reasoning that is explained accurately using at least three
different references from current evidence-based literature.
Fair 33 (33%) - 38 (38%)
The response vaguely or with some inaccuracy formulates a
different diagnosis of three possible considerations for the skin
graphic. The response determines the most likely correct
diagnosis with reasoning that is explained vaguely and with
some inaccuracy using three different references from current
evidence-based literature.
Poor 0 (0%) - 32 (32%)
The response formulates inaccurately, incompletely, or is
missing a different diagnosis of possible considerations for the
skin graphic, with two or fewer possible considerations
provided. The response vaguely, inaccurately, or incompletely
determines the most likely correct diagnosis with reasoning that
is missing or explained using two or fewer different references
18. from current evidence-based literature.
Feedback:
Written Expression and Formatting - Paragraph Development
and Organization:
Paragraphs make clear points that support well-developed ideas,
flow logically, and demonstrate continuity of ideas. Sentences
are carefully focused--neither long and rambling nor short and
lacking substance. A clear and comprehensive purpose
statement and introduction are provided that delineate all
required criteria.--
Levels of Achievement:
Excellent 5 (5%) - 5 (5%)
Paragraphs and sentences follow writing standards for flow,
continuity, and clarity. A clear and comprehensive purpose
statement, introduction, and conclusion are provided that
delineate all required criteria.
Good 4 (4%) - 4 (4%)
Paragraphs and sentences follow writing standards for flow,
continuity, and clarity 80% of the time. Purpose, introduction,
and conclusion of the assignment are stated, yet are brief and
not descriptive.
Fair 3 (3%) - 3 (3%)
Paragraphs and sentences follow writing standards for flow,
continuity, and clarity 60%–79% of the time. Purpose,
introduction, and conclusion of the assignment are vague or off
topic.
Poor 0 (0%) - 2 (2%)
Paragraphs and sentences follow writing standards for flow,
continuity, and clarity < 60% of the time. No purpose statement,
introduction, or conclusion were provided.
Feedback:
Written Expression and Formatting - English writing standards:
Correct grammar, mechanics, and proper punctuation--
Levels of Achievement:
Excellent 5 (5%) - 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
19. Good 4 (4%) - 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation
errors.
Fair 3 (3%) - 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation
errors.
Poor 0 (0%) - 2 (2%)
Contains many (≥ 5) grammar, spelling, and punctuation errors
that interfere with the reader’s understanding.
Feedback:
Written Expression and Formatting - The paper follows correct
APA format for title page, headings, font, spacing, margins,
indentations, page numbers, running heads, parenthetical/in-text
citations, and reference list.--
Levels of Achievement:
Excellent 5 (5%) - 5 (5%)
Uses correct APA format with no errors.
Good 4 (4%) - 4 (4%)
Contains a few (1 or 2) APA format errors.
Fair 3 (3%) - 3 (3%)
Contains several (3 or 4) APA format errors.
Poor 0 (0%) - 2 (2%)
Contains many (≥ 5) APA format errors.
Feedback:
Total Points: 100
Name: NURS_6512_Week_4_Assignment_1_Rubric
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21. %7B%220.30000
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REQUIRED READINGS
Note: To access this week's required library resources, please
click on the link to the Course Readings List, found in
the Course Materials section of your Syllabus.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2019). Seidel's guide to physical examination:
An interprofessional approach (9th ed.). St. Louis, MO: Elsevier
Mosby.
· Chapter 9, “Skin, Hair, and Nails”
This chapter reviews the basic anatomy and physiology of skin,
hair, and nails. The chapter also describes guidelines for proper
skin, hair, and nails assessments.
Colyar, M. R. (2015). Advanced practice nursing procedures.
Philadelphia, PA: F. A. Davis.
Credit Line: Advanced practice nursing procedures, 1st Edition
by Colyar, M. R. Copyright 2015 by F. A. Davis Company.
Reprinted by permission of F. A. Davis Company via the
Copyright Clearance Center.
This section explains the procedural knowledge needed prior to
performing various dermatological procedures.
Chapter 1, “Punch Biopsy”
Chapter 2, “Skin Biopsy”
22. Chapter 10, “Nail Removal”
Chapter 15, “Skin Lesion Removals: Keloids, Moles, Corns,
Calluses”
Chapter 16, “Skin Tag (Acrochordon) Removal”
Chapter 22, “Suture Insertion”
Chapter 24, “Suture Removal”
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced
health assessment and clinical diagnosis in primary care (6th
ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical
Diagnosis in Primary Care, 6th Edition by Dains, J.E.,
Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby.
Reprinted by permission of Mosby via the Copyright Clearance
Center.
Chapter 28, “Rashes and Skin Lesions”
This chapter explains the steps in an initial examination of
someone with dermatological problems, including the type of
information that needs to be gathered and assessed.
Note: Download and use the Student Checklist and the Key
Points when you conduct your assessment of the skin, hair, and
nails in this Week’s Lab Assignment.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2019). Skin, hair, and nails: Student checklist.
In Seidel's guide to physical examination (9th ed.). St. Louis,
MO: Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th
Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B.
S., & Stewart, R. W. Copyright 2019 by Elsevier Health
23. Sciences. Reprinted by permission of Elsevier Health Sciences
via the Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2019). Skin, hair, and nails: Key points. In
Seidel's guide to physical examination: An interprofessional
approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th
Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B.
S., & Stewart, R. W. Copyright 2019 by Elsevier Health
Sciences. Reprinted by permission of Elsevier Health Sciences
via the Copyright Clearance Center.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd
ed.). Philadelphia, PA: F. A. Davis.
· Chapter 2, "The Comprehensive History and Physical Exam"
(Previously read in Weeks 1 and 3)
VisualDx. (n.d.). Clinical decision support. Retrieved June 11,
2019, from http://www.skinsight.com/info/for_professionals
This interactive website allows you to explore skin conditions
according to age, gender, and area of the body.
Clothier, A. (2014). Assessing and managing skin tears in older
people. Nurse Prescribing, 12(6), 278–282. Retrieved from
https://search-ebscohost-
com.ezp.waldenulibrary.org/login.aspx?direct=true&db=rzh&A
N=103968541&site=ehost-live&scope=site
Note: You will access this article from the Walden Library
databases.
Document: Skin Conditions (Word document)
This document contains five images of different skin conditions.
24. You will use this information in this week’s Discussion.
Document: Comprehensive SOAP Exemplar (Word document)
Document: Comprehensive SOAP Template (Word document)
Comprehensive SOAP Exemplar
Purpose: To demonstrate what each section of the SOAP note
should include. Remember that Nurse Practitioners treat
patients in a holistic manner and your SOAP note should reflect
that premise.
Patient Initials: _______ Age: _______
Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC): Coughing up phlegm and fever
History of Present Illness (HPI): Sara Jones is a 65 year old
Caucasian female who presents today with a productive cough x
3 weeks and fever for the last three days. She reported that the
“cold feels like it is descending into her chest”. The cough is
nagging and productive. She brought in a few paper towels with
expectorated phlegm – yellow/brown in color. She has
associated symptoms of dyspnea of exertion and fever. Her
Tmax was reported to be 102.4, last night. She has been taking
Ibuprofen 400mg about every 6 hours and the fever breaks, but
returns after the medication wears off. She rated the severity of
her symptom discomfort at 4/10.
Medications:
1.) Lisinopril 10mg daily
2.) Combivent 2 puffs every 6 hours as needed
25. 3.) Serovent daily
4.) Salmeterol daily
5.) Over the counter Ibuprofen 200mg -2 PO as needed
6.) Over the counter Benefiber
7.) Flonase 1 spray each night as needed for allergic rhinitis
symptoms
Allergies:
Sulfa drugs - rash
Past Medical History (PMH):
1.) Emphysema with recent exacerbation 1 month ago – deferred
admission – RX’d with outpatient antibiotics and an hand held
nebulizer treatments.
2.) Hypertension – well controlled
3.) Gastroesophageal reflux (GERD) – quiet on no medication
4.) Osteopenia
5.) Allergic rhinitis
Past Surgical History (PSH):
1.) Cholecystectomy 1994
2.) Total abdominal hysterectomy (TAH) 1998
Sexual/Reproductive History:
Heterosexual
G1P1A0
Non-menstrating – TAH 1998
Personal/Social History:
She has smoked 2 packs of cigarettes daily x 30 years; denied
ETOH or illicit drug use.
Immunization History:
Her immunizations are up to date. She received the influenza
vaccine last November and the Pneumococcal vaccine at the
same time.
26. Significant Family History:
Two brothers – one with diabetes, dx at age 65 and the other
with prostate CA, dx at age 62. She has 1 daughter, in her 50’s,
healthy, living in nearby neighborhood.
Lifestyle:
She is a retired; widowed x 8 years; lives in the city, moderate
crime area, with good public transportation. She college
graduate, owns her home and receives a pension of $50,000
annually – financially stable.
She has a primary care nurse practitioner provider and goes for
annual and routine care twice annually and as needed for
episodic care. She has medical insurance but often asks for drug
samples for cost savings. She has a healthy diet and eating
pattern. There are resources and community groups in her area
at the senior center and she attends regularly. She enjoys bingo.
She has a good support system composed of family and friends.
Review of Systems:
General: + fatigue since the illness started; + fever, no chills or
night sweats; no recent weight gains of losses of significance.
HEENT: no changes in vision or hearing; she does wear glasses
and her last eye exam was 1 ½ years ago. She reported no
history of glaucoma, diplopia, floaters, excessive tearing or
photophobia. She does have bilateral small cataracts that are
being followed by her ophthalmologist. She has had no recent
ear infections, tinnitus, or discharge from the ears. She reported
her sense of smell is intact. She has not had any episodes of
epistaxis. She does not have a history of nasal polyps or recent
sinus infection. She has history of allergic rhinitis that is
seasonal. Her last dental exam was 3/2014. She denied
ulceration, lesions, gingivitis, gum bleeding, and has no dental
27. appliances. She has had no difficulty chewing or swallowing.
Neck: no pain, injury, or history of disc disease or compression.
Her last Bone Mineral density (BMD) test was 2013 and showed
mild osteopenia, she said.
Breasts: No reports of breast changes. No history of lesions,
masses or rashes. No history of abnormal mammograms.
Respiratory: + cough and sputum production (see HPI); denied
hemoptysis, no difficulty breathing at rest; + dyspnea on
exertion; she has history of COPD and community acquired
pneumonia 2012. Last PPD was 2013. Last CXR – 1 month ago.
CV: no chest discomfort, palpitations, history of murmur; no
history of arrhythmias, orthopnea, paroxysmal nocturnal
dyspnea, edema, or claudication. Date of last ECG/cardiac work
up is unknown by patient.
GI: No nausea or vomiting, reflux controlled, No abd pain, no
changes in bowel/bladder pattern. She uses fiber as a daily
laxative to prevent constipation.
GU: no change in her urinary pattern, dysuria, or incontinence.
She is heterosexual. She has had a total abd hysterectomy. No
history of STD’s or HPV. She has not been sexually active since
the death of her husband.
MS: she has no arthralgia/myalgia, no arthritis, gout or
limitation in her range of motion by report. No history of
trauma or fractures.
Psych: no history of anxiety or depression. No sleep
disturbance, delusions or mental health history. She denied
suicidal/homicidal history.
28. Neuro: no syncopal episodes or dizziness, no paresthesia, head
aches. No change in memory or thinking patterns; no twitches
or abnormal movements; no history of gait disturbance or
problems with coordination. No falls or seizure history.
Integument/Heme/Lymph: no rashes, itching, or bruising. She
uses lotion to prevent dry skin. She has no history of skin
cancer or lesion removal. She has no bleeding disorders,
clotting difficulties or history of transfusions.
Endocrine: no endocrine symptoms or hormone therapies.
Allergic/Immunologic: this has hx of allergic rhinitis, but no
known immune deficiencies. Her last HIV test was 10 years ago.
OBJECTIVE DATA
Physical Exam:
Vital signs: B/P 110/72, left arm, sitting, regular cuff; P 70 and
regular; T 98.3 Orally; RR 16; non-labored; Wt: 115 lbs; Ht:
5’2; BMI 21
General: A&O x3, NAD, appears mildly uncomfortable
HEENT: PERRLA, EOMI, oronasopharynx is clear
Neck: Carotids no bruit, jvd or tmegally
Chest/Lungs: CTA AP&L
Heart/Peripheral Vascular: RRR without murmur, rub or gallop;
pulses+2 bilat pedal and +2 radial
ABD: benign, nabs x 4, no organomegaly; mild suprapubic
tenderness – diffuse – no rebound
Genital/Rectal: external genitalia intact, no cervical motion
tenderness, no adnexal masses.
Musculoskeletal: symmetric muscle development - some age
related atrophy; muscle strengths 5/5 all groups.
Neuro: CN II – XII grossly intact, DTR’s intact
Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no
31. 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: Includelast Tdp, Flu, pneumonia, etc.
Significant Family History: Include history of parents,
Grandparents, siblings, and children.
Lifestyle: Include cultural factors, economic factors, safety, and
support systems.
Review of Systems: From head-to-toe, include each system that
covers the Chief Complaint, History of Present Illness, and
History (this includes the systems that address any previous
diagnoses).Remember that the information you include in this
32. section is based on what the patient tells you. You do not need
to do them all unless you are doing a total H&P. 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.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin: Include rashes, lumps, sores, itching, dryness,
changes, etc.
Hematologic:
Endocrine:
Allergic/Immunologic:
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, and BMI.
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.
HEENT:
33. Neck:
Chest/Lungs: Always include this in your PE.
Heart/Peripheral Vascular: Always include the heart in your PE.
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:
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. Include
any labs, x-rays, or other diagnostics that are needed to develop
the differential diagnoses.For holistic care, you need to include
previous diagnoses and indicate whether these are controlled or
not controlled. These should also be included in your treatment
plan.
PLAN: This section is not required for the assignments in this
course (NURS 6512), but will be required for future courses.
Treatment Plan: If applicable, include both pharmacological and
nonpharmacological strategies, alternative therapies, follow-up
recommendations, referrals, consultations, and any additional
labs, x-ray, or other diagnostics. Support the treatment plan
with evidence and guidelines.
Health Promotion: Include exercise, diet, and safety
recommendations, as well as any other health promotion
strategies for the patient/family. Support the health promotion
recommendations and strategies with evidence and guidelines.
Disease Prevention: As appropriate for the patient’s age,
include disease prevention recommendations and strategies such
as fasting lipid profile, mammography, colonoscopy,
immunizations, etc. Support the disease prevention
