Unit 4 Discussion 1 Critical Thinking and Diagnostic Reasoning Please select one of the following case studies and complete the chart. Please review audio-videos, PowerPoint presentations, and assigned chapters to assist with this Assignment. You are expected to role play the selected scenario with a family member to gather necessary data to complete the chart. For each person described in the following situations, discuss the developmental/age, socioeconomic, ethical considerations, and cross-cultural considerations that should be considered during the gathering of subjective and objective data, and the provision of health care. Discuss any additional information that might be needed before a judgment or diagnosis can be made. Submit the completed chart to the Discussion Board by Friday at 11:59 p.m. 1. A. E. is a 35-year-old African American female, and is 5 months pregnant presenting to the office today for a routine prenatal visit. She complains that her neck feels swollen and that she has been feeling nervous and tired. She also complains about the heat, excessive sweating, and how she “can’t seem to get cool during these summer months.” She attributes all these complaints to her pregnancy. 2. J. L. is a 55-year-old Caucasian female who had a CVA within the past week. J. L. is easily frustrated, anxious, fearful, and her speech is slurred. She needs verbal cuing for any task she is asked to carry out. She eats only food on the left side of the tray and responds only when approached from the left side. Components of assessment Subjective Diagnostic Reasoning (list key questions — use PQRSTU pneumonic) Objective Normal vs. abnormal findings (must note pertinent body systems to be examined) Differential diagnoses (list 3) Nurses diagnosis (list 1) List relevant labs and diagnostic studies (if any) Normal Differential Abnormal Findings Nurses Diagnosis Developmental/age considerations: Socioeconomic considerations: Cross-cultural considerations: Ethical considerations: Additional info needed to formulate actual diagnosis: MN552 Advanced Health Assessment Unit 3 SOAP Note Section II and III Written Guide 1. Document appropriate data in the relevant body system. a. Do not state “Negative, NA or Unremarkable” for any systems because the reader will not know which questions were actually asked by the provider. 2. This is a comprehensive health history and should not contain physical exam findings. The focused history data is relevant to the chief complaint and identified by pertinent positive data documented during the health history. 3. Address each component of the SOAP note as noted in the written guide with relevant data. 4. You may continue with the same volunteer to complete each section of the SOAP note. II. Life style patterns 0. Immigrant status: Born in San Diego, California. U.S. Citizen 0. Spiritual resources/religion: ...

1. Unit 4 Discussion 1
Critical Thinking and Diagnostic Reasoning
Please select one of the following case studies and complete the
chart. Please review audio-videos, PowerPoint presentations,
and assigned chapters to assist with this Assignment. You are
expected to role play the selected scenario with a family
member to gather necessary data to complete the chart. For each
person described in the following situations, discuss the
developmental/age, socioeconomic, ethical considerations, and
cross-cultural considerations that should be considered during
the gathering of subjective and objective data, and the provision
of health care. Discuss any additional information that might be
needed before a judgment or diagnosis can be made. Submit the
completed chart to the Discussion Board by Friday at 11:59 p.m.
1. A. E. is a 35-year-old African American female, and is 5
months pregnant presenting to the office today for a routine
prenatal visit. She complains that her neck feels swollen and
that she has been feeling nervous and tired. She also complains
about the heat, excessive sweating, and how she “can’t seem to
get cool during these summer months.” She attributes all these
complaints to her pregnancy.
2. J. L. is a 55-year-old Caucasian female who had a CVA
within the past week. J. L. is easily frustrated, anxious, fearful,
and her speech is slurred. She needs verbal cuing for any task
she is asked to carry out. She eats only food on the left side of
the tray and responds only when approached from the left side.
Components of
assessment
Subjective
Diagnostic Reasoning
(list key questions — use PQRSTU pneumonic)

2. Objective
Normal vs.
abnormal findings
(must note pertinent body systems to be examined)
Differential
diagnoses
(list 3)
Nurses diagnosis (list 1)
List relevant labs and
diagnostic studies (if any)
Normal
Differential

4. Abnormal Findings
Nurses Diagnosis

5. Developmental/age considerations:
Socioeconomic considerations:
Cross-cultural considerations:
Ethical considerations:
Additional info needed to formulate actual diagnosis:
MN552 Advanced Health Assessment
Unit 3 SOAP Note Section II and III Written Guide
1. Document appropriate data in the relevant body system.
a. Do not state “Negative, NA or Unremarkable” for any
systems because the reader will not know which questions were
actually asked by the provider.
2. This is a comprehensive health history and should not contain
physical exam findings. The focused history data is relevant to
the chief complaint and identified by pertinent positive data
documented during the health history.
3. Address each component of the SOAP note as noted in the
written guide with relevant data.
4. You may continue with the same volunteer to complete each
section of the SOAP note.
II. Life style patterns
0. Immigrant status: Born in San Diego, California. U.S. Citizen
0. Spiritual resources/religion: Christian
0. Health perception: Fair
0. Nutritional patterns: Appetite (any changes); satisfaction

6. with current weight; gains or losses; recall of usual intake; any
cultural restrictions/intolerances; amount of fluid per day and
type: Healthy appetite, stressed over recent weight gain, eats 3
meals per day and snacks in between meals, patient admits she
could benefit from eating healthier, and reduce portions. Patient
states she does not drink enough water, her intake is about 48oz
of fluids a day that include water, coffee, juices and tea. No
cultural restrictions.
0. Elimination patterns: Bowel (usual pattern and
characteristics); bladder (usual pattern and characteristics); any
incontinence. Daily bowel movement no use of laxatives,
polyuria, frequent urination throughout the day, no bedwetting
at night, narrowed stream, no incontinence, but sometimes has
small void when she sneezes.
0. Living environment:City, state; urban, rural, community; type
of dwelling, facilities; known exposures to environmental
toxins: Lives in a city, urban community, owns her own home,
no known exposure to environmental toxins, other than we she
goes downtown and sees buses drive by.
0. Occupational health: Known exposure to environmental
toxins at work. No known exposure to toxins at work, her work
is a no smoking environment.
0. Functional assessment: ADLs, IADLs, interpersonal
relationships/resources (see page 57 in Jarvis textbook): Patient
is 65 y/o and is independent with ADLs, very social, meets with
friends to play cards once a week. Patient has a driver’s license
in the state of California and drives.
0. Role and family relationships: Immediate family
composition; how are family decisions made; impact of family
member’s health on family: Patient was married but currently
divorced, lives with daughter and teenage grandson, patient
independent and makes own decisions regarding health and
daily activities, she is also an active member at church, pays her
own bills, is very capable of managing every day schedules.
0. Cognitive function:Memory; speech; judgment; senses:

7. Memory appropriate for her age, clear speech pattern.
0. Rest/sleep patterns: Number of hours; naps; number of
pillows; any aids for sleep. Sleeps approximately 7 hours at
night, does not nap in the day, uses 2 pillows, does not use
sleep aids in the form of OTC pills, she does enjoy a hot cup of
tea at bedtime that helps her relax.
0. Exercise patterns: Type and frequency: Enjoys walks in the
park, walks 3 days out of 7 days.
0. Hobbies/recreation: Leisure activities; any travel outside of
the US: Enjoys playing cards, and watching movies when
possible, has not traveled recently out of the USA but has
traveled in the past to Colombia, South America.
0. Social habits: Tobacco; alcohol; street drug use: Does not
drink socially or smoke cigarettes, has never experienced street
drugs.
0. Intimate partner violence (review screening questions on
page 58 in the Jarvis textbook): Not avictim of domestic
violence, patient is currently divorced and does not have an
intimate partner.
0. Coping/stress management: Any major life changes in past 2
years; do you feel tense; source; what helps: No major changes
in the past 2 years, her divorce was 10 years ago, patient states
at first it was hard to adapt but has coped well over the years
and feels emotionally healthy. At moments of tension, patient
enjoys relaxing over a nice walk in the park.
0. Sexual patterns: Are you sexually active; gender preference;
has anything changed about your sexual health/function:
Currently not sexually active, of heterosexual orientation, major
changes in her sexual health has been abstinence since her
divorce which she feels comfortable with, patient states that in
this stage of life she prefers to be alone and enjoy her family.
III. Review of Symptoms
Symptoms to Inquire About

8. (please see page 54–56 in Jarvis textbook)
Document pertinent negatives and/or positives
The first system is addressed to provide a guide
General
Wgt Δ; weakness; fatigue; fevers
Pertinent negatives: No weight gain or losses; no weaknesses,
fatigue, or fevers
Pertinent positives: Positive weight gain over past 2 months
with fatigue and weakness; no fevers
Skin
Rash; lumps; sores; itching; dryness; color change; Δ in
hair/nails
No skin rash, lumps, sores, minimal skin dryness, no itching, no
pigmentation changes in skin other than appropriate for age.
Head
Headache; head injury; dizziness or vertigo
No head injuries, no headaches, no problems with vertigo, or
dizziness.
Eyes
Vision Δ; eye pain, redness or swelling, corrective lenses; last
eye exam; excessive tearing; double vision; blurred vision;
scotoma
No eye pain, no redness, or swelling, change in vision
appropriate for age, wears reading glasses, last eye exam a year
ago, no tearing, double vision, blurred vision, or scotoma.
Ears
Hearing Δ; tinnitus; earaches; infections; discharge, hearing
loss, hearing aid use
No tinnitus, no earaches, or infections, no discharges, no
changes in hearing, no need for use of hearing aids.
Nose/
Sinuses
Colds; congestion; nasal obstruction, discharge; itching; hay
fever or allergies; nosebleeds; change in sense of smell; sinus

9. pain
No recent colds, congestion, or nasal obstruction, no nasal
drainage or discharge, no itching, hay fever or allergies but is
sensitive to strong odors. No H/O of nosebleeds, No sinus pains.
Throat/
Mouth
Bleeding gums; mouth pain, tooth ache, lesions in mouth or
tongue, dentures; last dental exam; sore tongue; dry mouth; sore
throats; hoarse; tonsillectomy; altered taste
Sensitive gums with minimum bleeding when flossing, no mouth
pain or sores, no lesions in mouth or tongue, wears dentures,
last dental exam was in 6 months ago, no sore throat or
hoarseness, no tonsillectomy, or noticed change in taste buds.
Neck
Lumps; enlarged or tender nodes, swollen glands; goiter; pain;
neck stiffness; limitation of motion
No palpable or visible lumps, enlarged or tender nodes, no
swollen glands, no goiter, slight pain in neck due to
degenerative changes, slight stiffness towards the end of the
day, No limitation of motion, right and left neck rotations, and
next extensions appropriate.
Breasts
Lumps; pain; discomfort; nipple discharge, rash, surgeries,
history of breast disease; performs self-breast exams and how
often, last mammogram; any tenderness, lumps, swelling, or
rash of axilla area
No visible or palpable right and breast lumps, no pain,
discomfort, nipple discharge, rash or surgeries, no history of
breast disease, performs self-breast exams monthly, last
mammogram one year ago, no lumps, tenderness or rash of
bilateral axilla’s.
Pulmonary
Cough — productive/non-productive; hemoptysis; dyspnea;
wheezing; pleuritic pains; any H/O lung disease; toxin or
pollution exposure; last Chest x-ray, TB skin test
Positive productive cough, no hemoptysis, dyspnea, or

10. wheezing, no pleuritic pains with cough or on inspiration, no
active H/O of lung disease, toxin or pollution exposure, last
Chest x-ray, and TB one year ago.
Cardiac
Chest pain or discomfort; palpitations; dyspnea; orthopnea;
edema, cyanosis, nocturia; H/O murmurs, hypertension, anemia,
or CAD
No chest pain or discomfort., no palpitations, dyspnea,
orthopnea edema, cyanosis. Positive for nocturia, 2 to 3 times a
night. No H/O murmurs, hypertension, anemia, or CAD.
G/I
Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn;
pain; belching/flatulence; Δ in bowel habits; hematochezia;
melena; hemorrhoids; constipation; diarrhea; food intolerance
Good appetite, no jaundice, nausea, emesis, dysphagia, positive
for heartburn associated with food, no pain, positive for
belching, no flatulence. No hematochezia in stool or with bowel
movement, melena, hemorrhoids or constipation. No diarrhea,
or food intolerance.
GU
Frequency; nocturia; urgency; dysuria; hematuria; incontinence
Females: Use of kegal exercises after childbirth; use of birth
control methods; HIV exposure; Menarche; frequency/duration
of menses; dysmenorrhea; PMS symptoms: bleeding between
menses or after intercourse; LMP; vaginal discharge; itching;
sores; lumps; menopause; hot flashes; post-menopausal
bleeding;
Males: Caliber of urinary stream; hesitancy; dribbling; hernia,
sexual habits, interest, function, satisfaction; discharge from or
sores on penis; HIV exposure; testicular pain/masses; testicular
exam and how often
Positive for nocturia, 2 to 3 times a night, no urgency, dysuria,
hematuria or incontinence. No H/O education of kegal exercises
after birth. No current use of birth control, negative for HIV
exposure. Menarche at age 12, 28-day cycle, duration of menses
3 to 4 days. No dysmenorrhea, positive PMS symptoms that

11. included mild pain. No bleeding between menses, or after
intercourse when was sexually active, LMP 9 years ago, no
vaginal discharge, itching, sores or lumps. Menopause at age
56, no hot flashes, no post-menopausal bleeding.
Peripheral Vascular
Claudication; coldness, tingling, and numbness; leg cramps;
varicose veins; H/O blood clots, discoloration of hands, ulcers
Positive claudication, no coldness, tingling or numbness,
positive leg cramps, varicose veins. No H/O of blood clots,
discoloration of the hands or ulcers.
Musculo-skeletal
Muscle or joint pain or cramps; joint stiffness; H/O arthritis or
Gout; limitation of movement; H/O disk disease
Positive for muscle, joint pain, and cramps associated with age,
minimal joint stiffness, no H/O arthritis, or Gout, no limitation
of movement or H/O disk disease.
Neuro
Syncope; seizures; weakness; paralysis; stroke,
numbness/tingling; tremors or tics; involuntary movements;
coordination problems; memory disorder or mood change; H/O
mental disorders or hallucinations
No syncope, seizures, weakness, paralysis, stroke,
numbness/tingling or tremors or tics, No involuntary
movements, coordination problems, memory disorder or mood
change, No H/O of mental disorder or hallucinations.
Heme
Hx of anemia; easy bruising or bleeding; blood transfusions or
reactions; lymph node swelling; exposure to toxic agents or
radiation
No H/O anemia, easy bruising or bleeding. No blood
transfusions or reactions. No lymph node swelling, exposure to
toxic agents or radiation.
Endo
Heat or cold intolerance; excessive sweating; polydipsia;
polyphagia; polyuria; glove or shoe size; H/O diabetes, thyroid
disease; hormone replacement; abnormal hair distribution

12. No heat or cold intolerance, no excessive sweating, polydipsia,
or polyphagia. Positive polyuria. H/O diabetes type 2, no H/O
thyroid disease, hormone replacement, or abnormal hair
distribution.
Psych
Nervousness/anxiety; depression; memory changes; suicide
attempts; H/O mental illnesses
No nervousness/anxiety, depression, or memory changes. No
suicide attempts or H/O mental illness.