Name:  Anna Jones  Pt. Encounter Number: 5663 Date: 9/13/22 Age: 54 Sex: Female SUBJECTIVE CC:  “low back pain radiating to left leg” HPI:  54 yo female presents to the office today c/o lower back pain radiating down L buttock, down the left leg through the calf. Began 3 days ago, with sudden onset while she was at work, following lifting and turning a patient.. She reports feeling a “pop” followed immediately by this pain. States the pain is constant and worsening and rates severity as 7/10. Describes the pain as throbbing, with stinging and tingling down the left leg and calf and reports she “feels crooked”. She has tried rest and Ibuprofen to treat the pain but has gotten no relief. She reports sitting worsens the pain and she is unable to walk without pain. Denies history of similar symptoms. No recent trauma. No previous treatment or testing related to this problem. Medications: Ibuprofen 400mg as needed for back pain Allergies: NKDA Medication Intolerances: none reported Past Medical History: Uterine fibroids Chronic Illnesses/Major traumas: denies Hospitalizations/Surgeries: 3 live births, partial hysterectomy due to uterine fibroids Preventive: Immunizations up to date .Tdap 2015, Flu 2019, COVID #1 Jan 2020, COVID#2 Feb 2020. Yearly dental exam. Mammogram March 2020. Family History Mother deceased due to COVID with history of asthma and smoking. Father living, age 86, HTN-controlled, smoker, depression. Social History Pt attended tech school and is working full time as a nursing assistant. Married and monogamous with husband. She has 3 children. Owns home and feels safe there. Denies smoking, tobacco or recreational drug use. Reports occasional use of wine. ROS Student to ask each of these questions to the patient: “Have you had any…..” General Denies weight change, fatigue, fever, chills, night sweats, or change in energy level Cardiovascular Denies chest pain, palpitations, edema. Skin Denies rashes, bruises or bleeding, or change in skin lesions. Respiratory Denies cough, SOB. Eyes Denies visual changes Gastrointestinal Denies abdominal pain, N/V/D, constipation, eating disorders or ulcer Ears Denies ear pain or hearing loss. Genitourinary/Gynecological Denies dysuria or incontinence. Reports last PAP 2010, normal. 3 live births. Nose/Mouth/Throat Denies congestion or sinus problems. Denies nosebleed. Denies dental disease. Denies sore throat or hoarseness Musculoskeletal Reports throbbing lower back pain, radiates to Left buttock and down to left leg/calf for 3 days. Worsening and causing pain when ambulating. Not relieved by rest, position change or Ibuprofen. Denies history of similar problems. Denies joint swelling or history of arthritis. Breast Reports regular SBE, Denies lumps or mass. Last mammogram March 2020 Neurological Alert and oriented x 4. Denies syncope, seizures. Reports stinging a ...

1. Name: Anna Jones
Pt. Encounter Number: 5663
Date: 9/13/22
Age: 54
Sex: Female
SUBJECTIVE
CC:
“low back pain radiating to left leg”
HPI:
54 yo female presents to the office today c/o lower back pain
radiating down L buttock, down the left leg through the calf.
Began 3 days ago, with sudden onset while she was at work,
following lifting and turning a patient.. She reports feeling a
“pop” followed immediately by this pain. States the pain is
constant and worsening and rates severity as 7/10. Describes the
pain as throbbing, with stinging and tingling down the left leg
and calf and reports she “feels crooked”. She has tried rest and
Ibuprofen to treat the pain but has gotten no relief. She reports
sitting worsens the pain and she is unable to walk without pain.
Denies history of similar symptoms. No recent trauma. No
previous treatment or testing related to this problem.
Medications: Ibuprofen 400mg as needed for back pain
Allergies: NKDA
Medication Intolerances: none reported
Past Medical History: Uterine fibroids

2. Chronic Illnesses/Major traumas: denies
Hospitalizations/Surgeries: 3 live births, partial hysterectomy
due to uterine fibroids
Preventive: Immunizations up to date .Tdap 2015, Flu 2019,
COVID #1 Jan 2020, COVID#2 Feb 2020. Yearly dental exam.
Mammogram March 2020.
Family History
Mother deceased due to COVID with history of asthma and
smoking. Father living, age 86, HTN-controlled, smoker,
depression.
Social History
Pt attended tech school and is working full time as a nursing
assistant. Married and monogamous with husband. She has 3
children. Owns home and feels safe there. Denies smoking,
tobacco or recreational drug use. Reports occasional use of
wine.
ROS Student to ask each of these questions to the patient:
“Have you had any…..”
General
Denies weight change, fatigue, fever, chills, night sweats, or
change in energy level
Cardiovascular
Denies chest pain, palpitations, edema.
Skin
Denies rashes, bruises or bleeding, or change in skin lesions.
Respiratory
Denies cough, SOB.
Eyes
Denies visual changes

3. Gastrointestinal
Denies abdominal pain, N/V/D, constipation, eating disorders or
ulcer
Ears
Denies ear pain or hearing loss.
Genitourinary/Gynecological
Denies dysuria or incontinence. Reports last PAP 2010,
normal. 3 live births.
Nose/Mouth/Throat
Denies congestion or sinus problems. Denies nosebleed. Denies
dental disease. Denies sore throat or hoarseness
Musculoskeletal
Reports throbbing lower back pain, radiates to Left buttock and
down to left leg/calf for 3 days. Worsening and causing pain
when ambulating. Not relieved by rest, position change or
Ibuprofen. Denies history of similar problems. Denies joint
swelling or history of arthritis.
Breast
Reports regular SBE, Denies lumps or mass. Last mammogram
March 2020
Neurological
Alert and oriented x 4. Denies syncope, seizures. Reports
stinging and tingling down left calf but denies numbness.
Heme/Lymph/Endo
Denies swollen or painful nodes, denies temperature
intolerance, night sweats .
Psychiatric
Denies depression. Reports anxiety and feeling overwhelmed,
but no previous evaluation or treatment. States she self-
medicates with exercise or occasional wine.
OBJECTIVE

4. Weight 110lbs BMI 17.8
Temp 98.3
BP 115/80 left, 116/82 right
Height 5’6’’
Pulse 76
Resp 24
O2 sat 99%
General Appearance
Healthy-appearing adult female in no acute distress.
Skin
Skin warm, dry, clean, and intact. No rashes or lesions noted.
HEENT
Head is normocephalic, atraumatic.. Eyes: PERRLA. EOMs
intact. No conjunctival or scleral injection. Ears: Canals patent.
Bilateral TM pearly gray, no bulging. Nose: Nasal mucosa pink;
normal turbinates. Neck: Supple. Full ROM. No
lymphadenopathy. Oral mucosa, pink and moist. Teeth are in
good repair.
Cardiovascular
S1, S2 with regular rate and rhythm. No clicks, rubs, or
murmurs. Capillary refills two seconds. Pulses 3+ throughout.
No edema.
Respiratory
Symmetric chest wall. Respirations regular and easy; lungs
clear to auscultation bilaterally.
Gastrointestinal
BS active in all the four quadrants. Abdomen soft, nontender.
No hepatosplenomegaly.

5. Breast
Deferred.
Genitourinary
No CVA tenderness. No incontinence during visit.
Musculoskeletal
Reduced forward flexion of lumbar spine. Left straight leg raise
limited to 45 degrees. Left leg sciatic stretch test positive.
Reduced response to light touch and pin prick lateral and dorsal
left calf. Grade 4 weakness on dorsiflexion of left foot. Reduced
right ankle jerk reflex. Negative reversed straight leg raise.
Normal curvature of cervical, thoracic and lumbar spine. Gait
slow and guarded. Spinal processes nontender. On standing, left
shoulder appears higher than right. Full ROM of upper
extremities.
Neurological
Oriented x 4 and answers questions appropriately. Speech clear.
Psychiatric
Maintains eye contact. Speech is of normal rate and cadence.
Normal mood and affect.
Lab Tests/Imaging
MRI-normal
Xray-normal
Assessment
· Include at least three differential diagnoses-acute low back
pain, sciatica, herniated disc
· Provide rationale for each differential diagnosis
· Final diagnosis -Acute low back pain, sciatica
· Pathophysiology of primary and rationale for choosing as final
Plan
· Medications
· Non-pharmacological recommendations
· Diagnostic tests
· Patient education

6. · Culture considerations
· Health promotion
· Referrals
· Follow up
Rubric Title: Unit 2, 4, 6 Lab – Virtual Reality Rubric
***Students: It is IMPORTANT to remember to utilize both the
“Guided Mode” and “Expert Mode” in the VR Lab Simulation
case scenario experiences, as you practice the VR Lab
scenario(s). The “Guided Mode” and “Expert Mode” allow you
to have multiple tries/attempts to practice the case. THEN,
when you feel you are ready, you will choose the VR Lab
“Exam Mode” (that you can ONLY attempt once); the score you
receive in “Exam Mode” will then be your final grade in the VR
Lab. If you have any questions regarding this, please follow up
with your course instructor.
Assignment Criteria
Level III
Level II
Level I
Not Present
Criteria 1
Level III
Points: 80
Level II
Points: 64
Level I
Points: 48

7. Not Present
0 Points
Total Score
· Within Exam Mode, obtains 65 to 80 points of the required
total components for virtual reality patient scenario
· Within Exam Mode, obtains between 49 to 64.9 points of the
required total components for virtual reality patient scenario
· Within Exam Mode, obtains between 33 to 48.9 points of the
required total components for virtual reality patient scenario
· Does not attempt in Exam Mode
· Does not meet the criteria
Rubric Title: Unit 3, 5, 7 SOAP Journal Assignment Rubric
Criteria 1
Level III Max Points
Points: 8
Level II Max Points
Points: 6.4
Level I Max Points
Points: 4.8
0 Points
Content Quality- Subjective Data
Subjective data displays complete understanding of all critical
concepts of virtual reality patient case including:
· Name, age, gender
· Chief complaint
· History of present illness (HPI) that follows OLD CARTS
pneumonic

8. · Medications
· Allergies
· Past medical history
· Past surgical history
· Pertinent family history
· Social history
· Review of Systems
· Subjective data displays understanding of critical concepts of
chosen virtual reality patient case; there may be 1-2 critical
concepts with errors/omissions or lack of details.
· Subjective data displays understanding of critical concepts of
chosen virtual reality patient case; there may be 3-4 critical
concepts with errors/omissions or lack of details.
· Does not meet criteria
Criteria 2
Level III Max Points
Points: 8
Level II Max Points
Points: 6.4
Level I Max Points
Points: 4.8
Not Present
0 Points
Content Quality- Objective Data
Objective data displays complete understanding of all critical
concepts of chosen virtual reality patient case including:
· Vital signs
· Body systems that are pertinent to specific case
· Objective data displays understanding of critical concepts of
chosen virtual reality patient case; there may be 1-2 critical
concepts with errors/omissions or lack of details.
· Objective data displays understanding of critical concepts of
chosen virtual reality patient case; there may be 3-4 critical
concepts with errors/omissions or lack of details

9. · Does not meet criteria
Criteria 3
Level III Max Points
Points: 4
Level II Max Points
Points: 3.2
Level I Max Points
Points: 2.4
Not Present
0 Points
Content Quality- Assessment
Assessment displays complete understanding of all critical
concepts of chosen virtual reality patient case including:
· Primary diagnosis
· Pathophysiology of primary diagnosis
· Three differential diagnoses
· Rationales for differential diagnoses
· Assessment displays understanding of critical concepts of
chosen virtual reality patient case; there may be 1 critical
concept with errors/omissions or lack of details.
· Assessment displays understanding of critical concepts of
chosen virtual reality patient case; there may be 2 critical
concepts with errors/omissions or lack of details.
· Does not meet criteria
Criteria 4
Level III Max Points
Points: 4
Level II Max Points
Points: 3.2
Level I Max Points
Points: 2.4
Not Present
0 Points
Content Quality- Plan of Care

10. Plan displays complete understanding of all critical concepts of
chosen virtual reality patient case including:
· Medications
· Non-pharmacological recommendations
· Diagnostic tests
· Patient education
· Cultural considerations
· Health promotion
· Referrals
· Follow-Up
· Plan displays understanding of critical concepts of chosen
virtual reality patient case; there may be 1 critical concept with
errors/omissions or lack of details.
· Plan displays understanding of critical concepts of chosen
virtual reality patient case; there may be 3-4 critical concepts
with errors/omissions or lack of details.
· Does not meet criteria
Criteria 5
Level III Max Points
Points: 3
Level II Max Points
Points: 2.4
Level I Max Points
Points: 1.8
Not Present
0 Points
Collegiate-level academic writing
· Includes no more than three grammatical, spelling, or
punctuation errors that do not interfere with the readabil ity.
· Supports all opinions and ideas with relevant and credible
reference sources of information.
· Provides three or more peer-reviewed or evidence-based
practice scholarly references sources.

11. · All reference sources are within the past five years.
· Includes no more than four grammatical, spelling, or
punctuation errors that do not interfere with the readability.
· Supports many opinions and ideas with relevant and credible
sources of information.
· Provides two peer-reviewed or evidence-based practice
scholarly references sources.
· All reference sources are within the past five years.
· Includes five or more grammatical, spelling, and punctuation
errors that makes understanding parts of assignment difficult,
but does not interfere with readability.
· Not all references utilized are relevant and/or credible sources
of information.
· Provides one peer-reviewed or evidence-based practice
scholarly references source.
· Reference sources are within the past five years.
· Does not meet criteria
Criteria 6
Level III Max Points
Points: 3
Level II Max Points
Points: 2.4
Level I Max Points
Points: 1.8
0 Points
Citations and Formatting
● The overall order of information is clear and contributes to
the meaning of the assignment. There may be 1-2 sentences, or
one paragraph that is out of order, or other minor organization
issues.
● Correctly citing all reference sources. One or two formatting,
in-text, or reference citation errors may occur.

12. ● Quotation marks and citations make authorship clear.
● The overall order of information is confusing in places due to
3-4 sentences, or two paragraphs that may be out of order, or
other organization issues that interfere with the meaning or
intent of the paper.
● Correctly citing all reference sources. 3-4 formatting, in-text,
or reference citation errors may occur.
● Quotation marks and citations generally, make authorship
clear.
● The overall order of information is confusing in places due to
5-6 sentences or three paragraphs that may be out of place, or
other organization issues that interfere with the meaning or
intent of the paper.
● Attempts to cite. 5-6 formatting, in-text, or reference citation
errors may occur.
● Quotation marks and citations may be missing or incorrect.
● Authorship may be unclear in areas.
· Does not meet criteria
Maximum Total Points
30
24
18
Minimum Total Points
25
19
Rubric Title: Unit 8 Journal Rubric
Criteria 1
Level III Max Points
Points: 15
Level II Max Points

13. Points: 12
Level I Max Points
Points:9
0 Points
Content Quality- Subjective Data
Presentation of subjective data displays complete understanding
of all critical concepts of chosen virtual reality patient case
including:
· Name, age, gender
· Chief complaint
· History of present illness (HPI) that follows OLD CARTS
pneumonic
· Medications
· Allergies
· Past medical history
· Past surgical history
· Pertinent family history
· Social history
· Review of Systems
· Presentation of subjective data displays understanding of all
critical concepts of chosen virtual reality patient case; there
may be 1-2 critical concepts with errors/omissions or lack of
details.
· Presentation of subjective data displays understanding of all
critical concepts of chosen virtual reality patient case; there
may be 3-4 critical concepts with errors/omissions or lack of
details.
· Does not meet the criteria
Criteria 2
Level III Max Points
Points: 15
Level II Max Points
Points: 12
Level I Max Points

14. Points:9
0 Points
Content Quality- Objective Data
Presentation of objective data displays complete understanding
of all critical concepts of chosen virtual reality patient case
including:
· Vital signs
· Body systems that are pertinent to specific case
· Presentation of objective data displays understanding of all
critical concepts of chosen virtual reality patient case; there
may be 1-2 critical concepts with errors/omissions or lack of
details.
· Presentation of objective data displays understanding of all
critical concepts of chosen virtual reality patient case; there
may be 3-4 critical concepts with errors/omissions or lack of
details.
· Does not meet the criteria
Criteria 3
Level III Max Points
Points: 15
Level II Max Points
Points: 12
Level I Max Points
Points:9
0 Points
Content Quality- Assessment
Presentation of assessment displays complete understanding of
all critical concepts of chosen virtual reality patient case
including:
· Primary diagnosis
· Pathophysiology of primary diagnosis
· Three differential diagnoses
· Rationales for differential diagnoses
· Presentation of assessment displays understanding of all

15. critical concepts of chosen virtual reality patient case; there
may be one critical concept with errors/omissions or lack of
details.
· Presentation of assessment displays understanding of all
critical concepts of chosen virtual reality patient case; there
may be two critical concepts with errors/omissions or lack of
details.
· Does not meet the criteria
Criteria 4
Level III Max Points
Points: 15
Level II Max Points
Points: 12
Level I Max Points
Points:9
0 Points
Content Quality- Plan of Care
Presentation of plan displays complete understanding of all
critical concepts of chosen virtual reality patient case including:
· Medications
· Non-pharmacological management
· Diagnostic tests
· Patient education
· Cultural considerations
· Health promotion
· Referrals
· Follow-Up
· Presentation of plan displays understanding of all critical
concepts of chosen virtual reality patient case; there may be one
critical concept with errors/omissions or lack of details.
· Presentation of plan displays understanding of all critical
concepts of chosen virtual reality patient case; there may be 3-4
critical concepts with errors/omissions or lack of details.s
· Does not meet the criteria
Criteria 5

16. Level III Max Points
Points: 15
Level II Max Points
Points: 12
Level I Max Points
Points:9
0 Points
Quality of Oral Presentation
· Presentation demonstrated thorough organization and delivery.
· All ideas were stated in a clear and logical manner.
· Presentation was on topic and relevant.
· Presentation time no longer than 5 minutes
· Presentation was organized and well spoken.
· All ideas were stated in a clear and logical manner.
· Presentation was on topic and relevant.
· Presentation >5 minutes
· Presentation needed more details or content inconclusive.
· Presentation >5 minutes
· Does not meet the criteria
Maximum Total Points
75
60
45
0
Minimum Total Points
61
46
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