Learning Resources Required Readings (click to expand/reduce) 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 7, “Mental Status” This chapter revolves around the mental status evaluation of an individual’s overall cognitive state. The chapter includes a list of mental abnormalities and their symptoms. · ·Chapter 23, “Neurologic System” The authors of this chapter explore the anatomy and physiology of the neurologic system. The authors also describe neurological examinations and potential findings. 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 4, “Affective Changes” This chapter outlines how to identify the potential cause of affective changes in a patient. The authors provide a suggested approach to the evaluation of this type of change, and they include specific tools that can be used as part of the diagnosis. Chapter 9, “Confusion in Older Adults” This chapter focuses on causes of confusion in older adults, with an emphasis on dementia. The authors include suggested questions for taking a focused history as well as what to look for in a physical examination. Chapter 13, “Dizziness” Dizziness can be a symptom of many underlying conditions. This chapter outlines the questions to ask a patient in taking a focused history and different tests to use in a physical examination. Chapter 19, “Headache” The focus of this chapter is the identification of the causes of headaches. The first step is to ensure that the headache is not a life-threatening condition. The authors give suggestions for taking a thorough history and performing a physical exam. Chapter 31, “Sleep Problems” In this chapter, the authors highlight the main causes of sleep problems. They also provide possible questions to use in taking the patient’s history, things to look for when performing a physical exam, and possible laboratory and diagnostic studies that might be useful in making the diagnosis. Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis. · Chapter 2, "The Comprehensive History and Physical Exam" ("Cranial Nerves and Their Function" and "Grading Reflexes") (Previously read in Weeks 1, 2, 3, and 5) Note: Download the Physical Examination Objective Data Checklist to use as you complete the Comprehensive (Head-to-Toe) Physical Assessment assignment. ...

1. Learning Resources
Required Readings (click to expand/reduce)
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 7, “Mental Status”
This chapter revolves around the mental status evaluation of an
individual’s overall cognitive state. The chapter includes a list
of mental abnormalities and their symptoms.
· ·Chapter 23, “Neurologic System”
The authors of this chapter explore the anatomy and physiology
of the neurologic system. The authors also describe neurological
examinations and potential findings.
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 4, “Affective Changes”
This chapter outlines how to identify the potential cause of

2. affective changes in a patient. The authors provide a suggested
approach to the evaluation of this type of change, and they
include specific tools that can be used as part of the diagnosis.
Chapter 9, “Confusion in Older Adults”
This chapter focuses on causes of confusion in older adults,
with an emphasis on dementia. The authors include suggested
questions for taking a focused history as well as what to look
for in a physical examination.
Chapter 13, “Dizziness”
Dizziness can be a symptom of many underlying conditions.
This chapter outlines the questions to ask a patient in taking a
focused history and different tests to use in a physical
examination.
Chapter 19, “Headache”
The focus of this chapter is the identification of the causes of
headaches. The first step is to ensure that the headache is not a
life-threatening condition. The authors give suggestions for
taking a thorough history and performing a physical exam.
Chapter 31, “Sleep Problems”
In this chapter, the authors highlight the main causes of sleep
problems. They also provide possible questions to use in taking
the patient’s history, things to look for when performing a
physical exam, and possible laboratory and diagnostic studies
that might be useful in making the diagnosis.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd
ed.). Philadelphia, PA: F. A. Davis.
· Chapter 2, "The Comprehensive History and Physical Exam"
("Cranial Nerves and Their Function" and "Grading Reflexes")
(Previously read in Weeks 1, 2, 3, and 5)
Note: Download the Physical Examination Objective Data
Checklist to use as you complete the Comprehensive (Head-to-

3. Toe) Physical Assessment assignment.
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon,
B. S., & Stewart, R. W. (2011). Physical examination objective
data checklist. In Mosby’s guide to physical examination (7th
ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Mosby’s Guide to Physical Examination, 7th
Edition by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A.,
Solomon, B. S., & Stewart, R. W. Copyright 2011 by Elsevier.
Reprinted by permission of Elsevier via the Copyright
Clearance Center.
Note: Download and review the Student Checklists and Key
Points to use during your practice neurological examination.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2019). Neurologic system: Student checklist. 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.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2019). Neurologic system: 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.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &

4. Stewart, R. W. (2019). Mental status: Student checklist. 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.
Bearden, S. T., & Nay, L. B. (2011). Utility of EEG in
differential diagnosis of adults with unexplained acute
alteration of mental status. American Journal of
Electroneurodiagnostic Technology, 51(2), 92–104.
Note: You will access this article from the Walden Library
databases.
This article reviews the use of electrocenographs (EEG) to
assist in differential diagnoses. The authors provide differential
diagnostic scenarios in which the EEG was useful.
Athilingam, P., Visovsky, C., & Elliott, A. F. (2015). Cognitive
screening in persons with chronic diseases in primary care:
Challenges and recommendations for practice. American Journal
of Alzheimer’s Disease & Other Dementias, 30(6), 547–558.
doi:10.1177/1533317515577127
Note: You will access this article from the Walden Library
databases.
Sinclair, A. J., Gadsby, R., Hillson, R., Forbes, A., & Bayer, A.
J. (2013). Brief report: Use of the Mini-Cog as a screening tool
for cognitive impairment in diabetes in primary care. Diabetes
Research and Clinical Practice, 100(1), e23–e25.
doi:10.1016/j.diabres.2013.01.001
Note: You will access this article from the Walden Library
databases.
Roalf, D. R., Moberg, P. J., Xei, S. X., Wolk, D. A., Moelter, S.
T., & Arnold, S. E. (2013). Comparative accuracies of two

5. common screening instruments for classification of Alzheimer’s
disease, mild cognitive impairment, and healthy aging.
Alzheimer’s & Dementia, 9(5), 529–537.
doi:10.1016/j.jalz.2012.10.001. Retrieved from
http://www.alzheimersanddementia.com/article/S1552-
5260(12)02463-6/abstr
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying why the
patient is here - in the patient’s own words - for instance
"headache", NOT "bad headache for 3 days”.
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. Use LOCATES Mnemonic to complete
your HPI. You need to start EVERY HPI with age, race, and
gender (e.g., 34-year-old AA male). You must include the seven
attributes of each 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
Current Medications: include dosage, frequency, length of time

6. used and reason for use; also include OTC or homeopathic
products.
Allergies: include medication, food, and environmental allergies
separately (a description of what the allergy is ie angioedema,
anaphylaxis, etc. This will help determine a true reaction vs
intolerance).
PMHx: include immunization status (note date of last tetanus
for all adults), past major illnesses and surgeries. Depending on
the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status,
tobacco & alcohol use (previous and current use), any other
pertinent data. Always add some health promo question here -
such as whether they use seat belts all the time or whether they
have working smoke detectors in the house, living environment,
text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition,
contagious or chronic illnesses. Reason for death of any
deceased first degree relatives should be included. Include
parents, grandparents, siblings, and children. Include
grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule
out a differential diagnosis 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.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or
yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing,
congestion, runny nose or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest
discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or

7. diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last
menstrual period, MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis,
ataxia, numbness or tingling in the extremities. No change in
bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or
stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat
intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O.
Physical exam: From head-to-toe, include what 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. Do not use “WNL” or “normal.” You must describe
what you see. Always document in head to toe format i.e.
General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics
that are needed to develop the differential diagnoses (support
with evidenced and guidelines)
A.
Differential Diagnoses (list a minimum of 3 differential
diagnoses).Your primary or presumptive diagnosis should be at
the top of the list. For each diagnosis, provide supportive
documentation with evidence based guidelines.
P.
This section is not required for the assignments in this course
(NURS 6512) but will be required for future courses.
References
You are required to include at least three evidence based peer-
reviewed journal articles or evidenced based guidelines which

8. relates to this case to support your diagnostics and differentials
diagnoses. Be sure to use correct APA 6th edition formatting.
© 2019 Walden University
Page 1 of 3
Episodic/Focused SOAP Note Exemplar
Focused SOAP Note for a patient with chest pain
S.
CC: “Chest pain”
HPI: The patient is a 65 year old AA male who developed
sudden onset of chest pain, which began early this morning.
The pain is described as “crushing” and is rated nine out of 10
in terms of intensity. The pain is located in the middle of the
chest and is accompanied by shortness of breath. The patient
reports feeling nauseous. The patient tried an antacid with
minimal relief of his symptoms.
PMH: Positive history of GERD and hypertension is controlled
FH: Mother died at 78 of breast cancer; Father at 75 of CVA.
No history of premature cardiovascular disease in first degree
relatives.
SH : Negative for tobacco abuse, currently or previously;
consumes moderate alcohol; married for 39 years
ROS
General--Negative for fevers, chills, fatigue

9. Cardiovascular--Negative for orthopnea, PND, positive for
intermittent lower extremity edema
Gastrointestinal--Positive for nausea without vomiting; negative
for diarrhea, abdominal pain
Pulmonary--Positive for intermittent dyspnea on exertion,
negative for cough or hemoptysis
O.
VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”
General--Pt appears diaphoretic and anxious
Cardiovascular--PMI is in the 5th inter-costal space at the mid
clavicular line. A grade 2/6 systolic decrescendo murmur is
heard best at the
second right inter-costal space which radiates to the neck.
A third heard sound is heard at the apex. No fourth heart sound
or rub are heard. No cyanosis, clubbing, noted, positive for
bilateral 2+ LE edema is noted.
Gastrointestinal--The abdomen is symmetrical without
distention; bowel
sounds are normal in quality and intensity in all areas; a
bruit is heard in the right para-umbilical area. No masses or
splenomegaly are noted. Positive for mid-epigastric tenderness
with deep palpation.
Pulmonary-- Lungs are clear to auscultation and percussion
bilaterally
Diagnostic results: EKG, CXR, CK-MB (support with evidenced

10. and guidelines)
A.
Differential Diagnosis:
1) Myocardial Infarction (provide supportive documentation
with evidence based guidelines).
2) Angina (provide supportive documentation with evidence
based guidelines).
3) Costochondritis (provide supportive documentation with
evidence based guidelines).
Primary Diagnosis/Presumptive Diagnosis: Myocardial
Infarction
P. This section is not required for the assignments in this course
(NURS 6512) but will be required for future courses.
© 2019 Walden University
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© 2019 Walden University

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