Name NURS_6512_Week_4_Assignment1_RubricList ViewExcellent .docx

Name: NURS_6512_Week_4_Assignment1_Rubric
List View
Excellent
Good
Fair
Poor
Quality of Work Submitted: The extent of which work meets the
assigned criteria and work reflects graduate level critical and
analytic thinking.
Points:
Points Range: 27 (27%) - 30 (30%)
Assignment exceeds expectations. All topics are addressed with
a minimum of 75% containing exceptional breadth and depth
about each of the assignment topics.
Feedback:
Points:
Points Range: 24 (24%) - 26 (26%)
Assignment meets expectations. All topics are addressed with a
minimum of 50% containing good breadth and depth about each
of the assignment topics.
Feedback:
Points:
Points Range: 21 (21%) - 23 (23%)
Assignment meets most of the expectations. One required topic
is either not addressed or inadequately addressed.
Feedback:
Points:
Points Range: 0 (0%) - 20 (20%)
Assignment superficially meets some of the expectations. Two

or more required topics are either not addressed or inadequately
addressed.
Feedback:
Assimilation and Synthesis of Ideas: The extent to which the
work reflects the student's ability to: Understand and interpret
the assignment's key concepts.
Points:
Points Range: 27 (27%) - 30 (30%)
Demonstrates the ability to critically appraise and intellectually
explore key concepts.
Feedback:
Points:
Points Range: 24 (24%) - 26 (26%)
Demonstrates a clear understanding of key concepts.
Feedback:
Points:
Points Range: 21 (21%) - 23 (23%)
Shows some degree of understanding of key concepts.
Feedback:
Points:
Points Range: 0 (0%) - 20 (20%)
Shows a lack of understanding of key concepts, deviates from
topics.
Feedback:
work reflects the student's ability to: Apply and integrate
material in course resources (i.e. video, required readings, and
textbook) and credible outside resources.
Points:
Points Range: 18 (18%) - 20 (20%)
Demonstrates and applies exceptional support of major points

and integrates 2 or more credible outside sources, in addition to
2-3 course resources to support point of view.
Feedback:
Points:
Points Range: 16 (16%) - 17 (17%)
Integrates specific information from 1 credible outside resource
and 2-3 course resources to support major points and point of
view.
Feedback:
Points:
Points Range: 14 (14%) - 15 (15%)
Minimally includes and integrates specific information from 2-3
resources to support major points and point of view.
Feedback:
Points:
Points Range: 0 (0%) - 13 (13%)
Includes and integrates specific information from 0 to 1
resource to support major points and point of view.
Feedback:
Written Expression and Formatting Paragraph/Sentence
Structure: Paragraphs make clear points that support well
developed ideas, flow logically, and demonstrate continuity of
ideas. Sentences are clearly structured and carefully focused--
neither long and rambling nor short and lacking substance.
Points:
Points Range: 9 (9%) - 10 (10%)
Paragraphs/Sentences follow writing standards for structure,
flow, continuity and clarity
Feedback:
Points:
Points Range: 8 (8%) - 8 (8%)

Paragraphs/sentences follow writing standards for structure,
flow, continuity and clarity 80% of the time.
Feedback:
Points:
Points Range: 7 (7%) - 7 (7%)
flow, continuity and clarity 60%- 79% of the time.
Feedback:
Points:
Points Range: 0 (0%) - 6 (6%)
flow, continuity and clarity < 60% of the time.
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: 3 (3%) - 4 (4%)
Contains a few (1-2) grammar, spelling, and punctuation errors.
Feedback:
Points:
Points Range: 2 (2%) - 2 (2%)
Contains several (3-4) grammar, spelling, and punctuation
errors.
Feedback:
Points:
Points Range: 0 (0%) - 1 (1%)

Contains many (≥ 5) grammar, spelling, and punctuation errors
that interfere with the reader’s understanding.
Feedback:
Written Expression and Formatting The assignment follows
parenthetical/in-text citations, and at least 3 evidenced based
references are listed.
Points:
Points Range: 5 (5%) - 5 (5%)
Contains parenthetical/in-text citations and at least 3 evidenced
based references are listed.
Feedback:
Points:
Points Range: 3 (3%) - 4 (4%)
based references are listed
Feedback:
Points:
Points Range: 2 (2%) - 2 (2%)
based reference is listed
Feedback:
Points:
Points Range: 0 (0%) - 1 (1%)
Contains no parenthetical/in-text citations and 0 evidenced
based references listed.
Feedback:
Show Descriptions Show Feedback
Quality of Work Submitted: The extent of which work meets the
assigned criteria and work reflects graduate level critical and
analytic thinking.--
Levels of Achievement:
Excellent 27 (27%) - 30 (30%)

Assignment exceeds expectations. All topics are addressed with
a minimum of 75% containing exceptional breadth and depth
about each of the assignment topics.
Good 24 (24%) - 26 (26%)
Assignment meets expectations. All topics are addressed with a
minimum of 50% containing good breadth and depth about each
of the assignment topics.
Fair 21 (21%) - 23 (23%)
Assignment meets most of the expectations. One required topic
is either not addressed or inadequately addressed.
Poor 0 (0%) - 20 (20%)
Assignment superficially meets some of the expectations. Two
or more required topics are either not addressed or inadequately
addressed.
Feedback:
work reflects the student's ability to: Understand and interpret
the assignment's key concepts.--
Excellent 27 (27%) - 30 (30%)
Demonstrates the ability to critically appraise and intellectually
explore key concepts.
Good 24 (24%) - 26 (26%)
Demonstrates a clear understanding of key concepts.
Fair 21 (21%) - 23 (23%)
Shows some degree of understanding of key concepts.
Poor 0 (0%) - 20 (20%)
Shows a lack of understanding of key concepts, deviates from
topics.
Feedback:
work reflects the student's ability to: Apply and integrate
material in course resources (i.e. video, required readings, and
textbook) and credible outside resources.--
Excellent 18 (18%) - 20 (20%)

Demonstrates and applies exceptional support of major points
and integrates 2 or more credible outside sources, in addition to
2-3 course resources to support point of view.
Good 16 (16%) - 17 (17%)
Integrates specific information from 1 credible outside resource
and 2-3 course resources to support major points and point of
view.
Fair 14 (14%) - 15 (15%)
Minimally includes and integrates specific information from 2-3
resources to support major points and point of view.
Poor 0 (0%) - 13 (13%)
Includes and integrates specific information from 0 to 1
resource to support major points and point of view.
Feedback:
Written Expression and Formatting Paragraph/Sentence
Structure: Paragraphs make clear points that support well
developed ideas, flow logically, and demonstrate continuity of
ideas. Sentences are clearly structured and carefully focused--
neither long and rambling nor short and lacking substance.--
Excellent 9 (9%) - 10 (10%)
Paragraphs/Sentences follow writing standards for structure,
flow, continuity and clarity
Good 8 (8%) - 8 (8%)
flow, continuity and clarity 80% of the time.
Fair 7 (7%) - 7 (7%)
flow, continuity and clarity 60%- 79% of the time.
Poor 0 (0%) - 6 (6%)
flow, continuity and clarity < 60% of the time.
Feedback:
Written Expression and Formatting English writing standards:
Correct grammar, mechanics, and proper punctuation.--

Excellent 5 (5%) - 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
Good 3 (3%) - 4 (4%)
Contains a few (1-2) grammar, spelling, and punctuation errors.
Fair 2 (2%) - 2 (2%)
Contains several (3-4) grammar, spelling, and punctuation
errors.
Poor 0 (0%) - 1 (1%)
Contains many (≥ 5) grammar, spelling, and punctuation errors
that interfere with the reader’s understanding.
Feedback:
Written Expression and Formatting The assignment follows
parenthetical/in-text citations, and at least 3 evidenced based
references are listed.--
Excellent 5 (5%) - 5 (5%)
based references are listed.
Good 3 (3%) - 4 (4%)
based references are listed
Fair 2 (2%) - 2 (2%)
based reference is listed
Poor 0 (0%) - 1 (1%)
Contains no parenthetical/in-text citations and 0 evidenced
based references listed.
Feedback:
Total Points: 100
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%7B%220.180000

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%7B%220.140000
%7B%220.090000
%7B%220.080000
%7B%220.070000
%7B%220.050000
%7B%220.270000
%7B%220.030000
%7B%220.020000
%7B%220.240000
8-3
RTF-downloadable Physical Exam Summary
Mosby items and derived items © 2011 by Mosby, Inc., an
affiliate of Elsevier Inc.
Seidel: Mosby’s Guide to Physical Examination, 7th Edition
Chapter 8: Skin, Hair, and Nails
RTF-downloadable Physical Exam Summary
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; 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.
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 between body areas, and compare sun-
exposed areas to areas that were not exposed to the sun.Second,
observe the skin as each part of the body is examined.During
inspection, expose the skin completely. As you finish inspecting
each area, remember to redrape or cover the patient for warmth
and modesty.
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 in areas of pressure or rubbing, such as the 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, 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, describes their
configuration as annular (or ring-shaped), arciform (or bow-
shaped), grouped, linear, or diffuse.Also 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, such
as 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 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 varies 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 five 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.And 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 or 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
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.

1:
2:
3.
4.
5.
ADULT EXAMINATION CHECKLIST
Guide for Skin, Hair, and Nails
Check (✔) if normal, * if abnormal, Ø if absent
Subjective Data
Skin Hair
______ Eruptions ______ Use of dyes, permanents
______ Lesions/sores/rashes ______ Changes in:
______ Color changes ______ Amount
______ Texture changes ______ Texture
______ Bruising ______ Character
______ Infections ______ Hair loss
______ Birthmarks ______ Hair care:
______ Skin growths ______ Shampoo
______ Acne ______ Conditioner
______ Moles ______ Distribution
______ Itching ______ Body hair
______ Masses ______ Hair on head
______ Excessive sweating ______ Shaving
______ Skin care ______ Face

______ Bathing ______ Axillary
______ Soaps ______ Legs
______ Lotions
______ Pigmentation changes or Nails
discoloration ______ Changes in appearance
______ Splitting
______ Cracking
______ Peeling
______ Discoloration
______ Texture
______ Nail care
Detail those marked abnormal:
_____________________________________________________
________________________
_____________________________________________________
________________________
_____________________________________________________
________________________
_____________________________________________________
________________________
_____________________________________________________
________________________
_____________________________________________________
________________________
_____________________________________________________
________________________

Objective Data: Inspection and Palpation
Skin Primary Lesions
Configuration of Lesions
______ Grouped (clustered) ______ Macule (flat, < 1 cm)
______ Herpetiform (Zosteriform)—nerve ______ Patch (> 1
cm)
______ Linear (line) ______ Papule (palpable, < 1 cm)
______ Annular (circle) ______ Plaque (> 1 cm)
______ Polycyclic (multiple circles) ______ Nodule (solid,
raised, deep, 1-2 cm)
______ Arciform (bow-shaped) ______ Tumor (2 cm)
______ Reticular (lesions meshed) ______ Vesicle (fluid-filled,
< 1 cm)
______ Confluent (lesions merged) ______ Bulla (> 1 cm)
______ Discrete (individual) ______ Pustule (purulent
vesicle/bulla)
______ Iris/target (concentric rings) ______ Wheal (cutaneous
edema)
______ Gyrate (spiral) ______ Cyst (encapsulated)
Color of Lesions Secondary Lesions
__________________________________ ______ Scale (loose
surface epithelium)
__________________________________ ______ Crust (dried
surface fluids)
__________________________________ ______ Excoriation
(scratch)
______ Erosion (loss of epidermis)
Description of Lesions ______ Scar
__________________________________ ______ Ulcer (loss of
epidermis, dermis)
__________________________________ ______ Atrophy
__________________________________ ______ Keloid
(enlarged scar)

______ Fissure (crack)
Texture and Firmness ______ Lichenification (thickened, with
irrita-
__________________________________ tion)
__________________________________
__________________________________
Distribution
__________________________________
__________________________________
__________________________________
Vascular Lesions
______ Purpura (red/purple, > 0.5 cm) ______ Mongolian spots
______ Petechiae (< 0.5 cm) ______ Pattern injuries
______ Ecchymosis (bruise) Location
________________________
______ Spider angioma ________________________________
(red body, radiating legs)
________________________________
______ Venous star (blue spider, linear)
________________________________
______ Telangiectasia ______ Dry skin
(dilated capillaries) Location ________________________
______ Capillary hemangioma
________________________________
(red, irregular patches) ________________________________

______ Cherry angioma ________________________________
______ Strawberry angioma ______ Skin turgor
______ Port-wine stain ______ Tenting
______ < 2 sec
Other Skin Lesions ______ 2-3 sec
______ Corn ______ 3-4 sec
______ Callus ______ > 4 sec
______ Cutaneous tag
______ Contact dermatitis
Other Skin Conditions Detail those marked abnormal:
______ Pallor ______________________________________
Location __________________
______________________________________
__________________________
______________________________________
__________________________
______________________________________
______ Erythema ______________________________________
Location __________________
______________________________________
__________________________
______________________________________
__________________________
______________________________________
______ Cyanosis
Location __________________ Hair: Inspection and Palpation
__________________________ ______ Texture
_________________________
__________________________ ______ Color
___________________________

______ Jaundice ______ Distribution
______ Vitiligo Body ___________________________
______ Location __________________
________________________________
__________________________ Head
___________________________
__________________________
________________________________
________________________________
______ Clean shaven
Thickness _______________________
________________________________
______ Dryness
______ Inflammation Detail those marked abnormal:
______ Alopecia ______________________________________
____________________________
______________________________________
______________________________________
Nails: Inspection and Palpation
______________________________________
______ Color _______________________
______________________________________
______ Length______________________
______________________________________

______ Clean ______________________________________
______ Pigment deposits
______________________________________
______ Bands ______________________________________
______ Streaks ______________________________________
______ Spots ______________________________________
______ Smooth nail edges
______________________________________
______ Ridging ______________________________________
______ Grooves ______________________________________
______ Pitting ______________________________________
______ Curved, smooth nail plate
______________________________________
______ Nail base angle—160 degrees
______________________________________
______ Adheres to nail bed
______________________________________
______ Clubbing ______________________________________
Comprehensive SOAP Template
This template is for a full history and physical. For this course
include only areas that are related to the case.
Patient Initials: _______
Age: _______
Gender: _______
Note: The mnemonic below is included for your reference and

should be removed before the submission of your final note.
L =location
O= onset
C= character
A= associated signs and symptoms
T= timing
E= exacerbating/relieving factors
S= severity
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 (e.g., 34-year-old AA
male). You must include the seven attributes ofeach principal
symptom in paragraph form not a list. If the CC was
“headache”, the LOCATES for the HPI might look like the
following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia,
phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes
it tolerable but not completely better
Severity: 7/10 pain scale
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. Identify if it is an allergy or
intolerance.
Past Medical History (PMH): Include illnesses (also childhood
illnesses), hospitalizations.
Past Surgical History (PSH): Include dates, indications, and
types of operations.
Sexual/Reproductive History: If applicable, include obstetric
history, menstrual history, methods of contraception, sexual
function, and risky sexual behaviors.
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 Tdap, Flu, pneumonia, etc.
Significant Family History: Include history of parents,
grandparents, siblings, and children.
Lifestyle: Include cultural factors, economic factors, safety, and
support systems and sexual preference.
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
section is based on what the patient tells you so 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:
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- only in this course.
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
consciousness, and affect and reactions to people and things.
HEENT:
Neck:
Chest
Lungs:
Heart
Peripheral Vascular: Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:
Include any labs, x-rays, or other diagnostics that are needed to
develop the differential diagnoses.
ASSESSMENT: List your priority diagnosis (es). For each
priority diagnosis, list at least three 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. 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.
REFLECTION:This section is not required for the assignments

in this course (NURS 6512) but will be required for future
courses. Reflect on your clinical experience, and consider the
following questions: What did you learn from this experience?
What would you do differently? Do you agree with your
preceptor based on the evidence?
© 2014 Laureate Education, Inc.
Page 2 of 3
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 3 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
it 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
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 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-menstruating – 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.
Significant Family History:
Two brothers – one with diabetes, dx at age 65, and the other
with prostate CA, dx at age 62. She has one daughter in her 30s,
healthy, living in nearby neighborhood.
Lifestyle:
She is retired, has been widowed x 8 years, and lives in the city
in a moderate crime area with good public transportation. She is
a 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 that 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 a 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
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 STDs 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.
Neuro: No syncopal episodes or dizziness, no paresthesia,
headaches. 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: 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
palpable nodes
ASSESSMENT:
Lab Tests and Results:
CBC – WBC 15,000 with + left shift
SAO2 – 98%
Diagnostics:
Lab:
Radiology:
CXR – cardiomegaly with air trapping and increased AP
diameter
ECG
Normal sinus rhythm

Differential Diagnosis (DDx):
1.) Acute Bronchitis
2.) Pulmonary Embolis
3.) Lung Cancer
Diagnoses/Client Problems:
1.) COPD
2.) HTN, controlled
3.) Tobacco abuse – 40-pack-a-year history
4.) Allergy to sulfa drugs – rash
5.) GERD – quiet, on no current medication
PLAN: [This section is not required for the assignments in this
course but will be required for future courses.]
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