Assignment Prompt & Instructions
**files (5)**
– ## SimulationcasestudyModul3.docx
– ## NURS_6512_Assessment_ReferenceSheet.pdf
– ## NURS_6512_PhysicalExamination_ReferenceSheet.pdf
– ## NURS_6512_ComprehensiveHealthHistory_ReferenceSheet1.pdf
– ## NURS_6512_M3AS2_Assignment_Template.docx
**## SimulationcasestudyModul3.docx**
**Simulation Case Studies -Burning In Chest After Eating**
**Burning in Chest After Eating Presentation**
**Angela Brooks**
**Age:** 52
**Sex:** Female
**Race/Ethnicity:** African American
**Marital Status:** Divorced
**Occupation:** Real Estate Agent
**Insurance:** Private
**Living Situation:** Lives alone
**Chief Complaint (CC):** Burning in Chest After Eating
**Patient Statement**
For about the past three or four months, I’ve been getting this burning feeling in the middle of my chest after I eat. It usually starts about 30 minutes to an hour after meals, especially if I eat something spicy or fried. Sometimes it feels like the food is coming back up into my throat, and I get a sour taste in my mouth.
It’s not really a sharp pain — more like a burning pressure. I’d rate it about a 5 out of 10. It’s worse when I lie down at night, and I’ve had to prop myself up on pillows. I’ve also noticed I clear my throat a lot in the mornings.
I haven’t had shortness of breath. No sweating. No pain going into my arm or jaw. I haven’t thrown up, and I haven’t seen any blood. My weight has been stable.
I drink coffee every morning and usually have a glass of wine a few nights a week. I’ve been under some stress lately and probably eat out more than I should. I’ve been taking over-the-counter antacids, and they help, but the symptoms keep coming back.
© 2026 Walden University, LLC
## image1.jpeg
**## NURS_6512_Assessment_ReferenceSheet.pdf**
NURS 6512: Assessment Reference Sheet
Purpose
To guide you in writing a clear, logical Assessment, including differential diagnoses, one final
diagnosis supported by evidence, and required references supporting clinical reasoning.
Overview of Expectations
– Include 3–5 differential diagnoses.
– Select ONE final diagnosis.
– Support all reasoning with subjective and objective findings.
– Use professional, concise clinical language.
– Include 3–5 peer-reviewed references (≤5 years old) to support diagnostic reasoning.
Differential Diagnoses (3–5 Required)
Differential #1
Condition:
Rationale:
Subjective findings (supporting):
–
Subjective findings (non-supporting/absent):
–
Objective findings (supporting):
–
Objective findings (non-supporting/absent):
–
Differential #2
Condition:
Rationale:
Subjective findings (supporting):
–
Subjective findings (non-supporting/absent):
–
Objective findings (supporting):
–
Objective findings (non-supporting/absent):
–
Differential #3
Condition:
Rationale:
Subjective findings (supporting):
–
Subjective findings (non-supporting/absent):
–
Objective findings (supporting):
–
Objective findings (non-supporting/absent):
–
Differential #4 (Optional)
Differential #5 (Optional)
Final Diagnosis (ONE ONLY)
Final Diagnosis: [Write the final diagnosis here]
Final Problem Statement Template
[Initials/Name], [Age], presents with [chief complaint] characterized by [positive subjective
findings] and denies [negative subjective findings]. Physical exam reveals [positive objective
findings] with absence of [negative objective findings]. Pertinent history includes [relevant PMH,
family history, or risk factors]. The overall clinical picture is most consistent with [final diagnosis].
Reference Requirements
You must include 3–5 peer-reviewed journal references (published within the last 5 years) to
support diagnostic reasoning in the Assessment. References must:
– Align with the differential diagnoses and/or final diagnosis.
– Support pathophysiology, clinical presentation, or diagnostic criteria.
– Be cited in APA 7th edition format.
– Not include textbooks, blogs, or patient-education websites.
Example acceptable sources:
– Peer-reviewed journal articles
– Clinical practice guidelines (ACC/AHA, ADA, IDSA, AAP, USPSTF)
– Systematic reviews or meta-analyses
**## NURS_6512_PhysicalExamination_ReferenceSheet.pdf**
NURS 6512: Physical Examination Reference Sheet
NURS 6512 – Advanced Health Assessment & Diagnostic Reasoning
Purpose: To guide students in documenting objective findings only during the physical
examination.
REMINDER: PHYSICAL EXAM = OBJECTIVE DATA ONLY
This section should include only what you observe, measure, or assess — not what the patient
reports. Do NOT include subjective statements or history.
✅ Correct (Objective): “Lungs clear to auscultation bilaterally; no wheezes, rales, or rhonchi.”
❌ Incorrect (Subjective): “Patient reports shortness of breath and chest tightness.”
GENERAL FORMAT FOR PHYSICAL EXAM DOCUMENTATION
• General: Appearance, distress, hygiene, orientation
• Skin: Color, temperature, turgor, lesions, rashes
• Head: Normocephalic, atraumatic
• Eyes: PERRLA, EOMI, conjunctiva clear
• Ears: TM intact, no erythema or effusion
• Nose: Mucosa pink, septum midline, no discharge
• Mouth/Throat: Mucosa moist, no erythema or exudate
• Neck: Supple, no lymphadenopathy, thyroid non-enlarged
• Cardiac: RRR, no murmurs, rubs, or gallops
• Lungs: CTA bilaterally, no wheezes, rales, or rhonchi
• Abdomen: Contour, bowel sounds, tenderness, organomegaly
• GU: External genitalia, discharge, lesions, CVA tenderness (as indicated)
• Musculoskeletal: ROM, strength, gait, deformities, tenderness
• Lower Extremities: Edema, pulses, color, warmth, capillary refill, sensation
• Neuro: CN II–XII grossly intact, strength and sensation symmetrical
Chief Complaint, Must-Not-Miss Diagnoses, and Systems to Examine
Identify high-priority conditions and focus your exam to rule them out.
Chief Complaint Must-Not-Miss Diagnoses Systems to Examine
Cough or Shortness of
Breath
Pneumonia, Pulmonary
embolism, Myocardial
infarction, Heart failure,
Pneumothorax
Respiratory, Cardiac, ENT,
Skin (cyanosis), Lower
Extremities (edema/DVT
signs)
Abdominal Pain Appendicitis, Bowel
obstruction, Perforated
Abdomen, GU, Cardiac,
Respiratory, Skin
ulcer, Ectopic pregnancy,
Cholecystitis, Pancreatitis
(jaundice), Neuro (pain
localization)
Headache Subarachnoid hemorrhage,
Meningitis, Temporal
arteritis, Intracranial mass,
Hypertensive emergency,
CVA (stroke)
Neuro, HEENT, Neck, Eyes
(fundoscopic), Cardiac (BP),
Skin (rash/meningitis)
Back Pain Cauda equina syndrome,
Epidural abscess, Spinal
fracture, Pyelonephritis,
Abdominal aortic aneurysm
(AAA)
Musculoskeletal, Neuro,
Abdomen, GU (CVA
tenderness), Skin
(infection)
UTI Symptoms Pyelonephritis, Urosepsis,
Pregnancy, Obstructive
uropathy
Abdomen, GU, CVA
tenderness, Skin (fever
signs), Neuro (confusion in
elderly)
Sore Throat Peritonsillar abscess,
Epiglottitis, Mononucleosis,
Streptococcal pharyngitis
HEENT, Lymphatic, Neck,
Cardiac, Respiratory
(airway), Skin
(rash/scarlatina)
Rash Cellulitis, Meningococcemia,
Stevens-Johnson syndrome,
Drug reaction, Anaphylaxis
Skin, Lymphatic, HEENT
(mucosal lesions),
Respiratory (distress),
Cardiac (shock signs)
Extremity/Joint Pain DVT, Septic joint, Fracture,
Cellulitis, Compartment
syndrome
Musculoskeletal, Neuro,
Lower Extremities (pulses,
edema, warmth, sensation),
Skin
DOCUMENTATION TIP
• Use head-to-toe format only for comprehensive exams (annuals, new patient, baseline).
• Use focused format for problem-based visits.
• Objective findings should align with your assessment and must-not-miss differential diagnoses.
**## NURS_6512_ComprehensiveHealthHistory_ReferenceSheet1.pdf**
NURS 6512: Comprehensive Health History Reference Sheet
⚠ Reminder: The health history includes **subjective data only** — information
provided by the patient about their symptoms, perceptions, and experiences.
Objective findings belong in the physical exam section.
Chief Complaint (CC)
• State the patient’s main reason for visit — concise and focused.
• Use the patient’s own words in quotes (1–2 words or one short sentence).
• Example: “Sore throat for two days.” or “Shortness of breath.”
History of Present Illness (HPI) – OLDCARTS + Pertinent History
• Use OLDCARTS to gather data, then synthesize into a cohesive paragraph written
in complete sentences.
• Avoid bullet points. Tell the story of the symptom(s) using the data you collected.
• O – Onset: When did it start?
• L – Location: Where is it? Does it radiate?
• D – Duration: Constant or intermittent?
• C – Character: Describe the quality (sharp, dull, throbbing).
• A – Aggravating factors: What makes it worse?
• R – Relieving factors: What makes it better?
• T – Timing: Pattern, frequency, time of day.
• S – Severity: 0–10 pain scale or functional impact.
• Include associated symptoms and pertinent negatives (important symptoms the
patient denies).
• Incorporate pertinent history such as recent illness, exposures, travel, medications
tried, previous episodes, or related chronic conditions.
• Example: The HPI should read as a full paragraph that flows logically and reflects
critical thinking — not as a list of OLDCARTS items.
Past Medical History (PMH)
• Chronic illnesses (HTN, DM, asthma, etc.)
• Childhood illnesses (if relevant)
• Hospitalizations and psychiatric history
Surgical History (PSH)
• List all surgeries/procedures with year, indication, and complications
Medications
• List all: prescription, OTC, herbal, and supplements
• Include name, dose, route, frequency, indication
• Note adherence and side effects
Allergies
• Drug, food, environmental — include reaction type (rash, anaphylaxis, etc.)
• Document tolerated alternatives if known
Preventive Health
• Immunizations: Flu, COVID-19, Tdap, shingles, pneumococcal
• Screenings: Pap, mammogram, colonoscopy, lipid, glucose, DEXA
• Risk factors: Diet, exercise, safety, sexual health, sleep, stress, dental, vision
Social History
• Tobacco: Type, amount, duration, quit attempts
• Alcohol: Type, frequency, quantity (CAGE if indicated)
• Substance use: Illicit or prescription misuse
• Occupation: Exposures, stress, satisfaction
• Living situation & support system
• Safety: IPV, firearms, seatbelt use
• Social Determinants of Health (SDOH): Housing, food, transport, access, finances
Review of Systems (ROS)
These are subjective symptoms that the patient reports. No objective exam findings
should be included here.
• General: Fever, chills, weight change, fatigue
• Skin: Rashes, lesions, itching
• HEENT: Vision, hearing, congestion, sore throat
• Cardiac: Chest pain, palpitations, edema
• Respiratory: Cough, SOB, wheezing
• GI: N/V/D, constipation, pain, appetite
• GU: Dysuria, frequency, hematuria
• MSK: Joint pain, stiffness, weakness
• Neuro: Headache, dizziness, numbness, seizures
• Psych: Mood, anxiety, sleep
• Endo: Heat/cold intolerance, polyuria/polydipsia
• Heme: Easy bruising/bleeding
**## NURS_6512_M3AS2_Assignment_Template.docx**
**NURS 6512**
**Week 7 Assignment Template**
**Comprehensive Health History, Physical Examination, and Assessment Template**
**Part I: Comprehensive Health History (Subjective Data Only)**
**Subjective Data**
Chief Complaint (CC):
History of Present Illness (HPI):
Past Medical History (PMH):
Surgical History (PSH):
Medications:
Allergies:
Preventive Health:
Social History:
**Review of Systems (ROS) (Subjective Data Only – Patient-Reported Symptoms):**
General:
Skin:
HEENT:
Cardiac:
Respiratory:
Gastrointestinal (GI):
Genitourinary (GU):
Musculoskeletal (MSK):
Neurologic:
Psychiatric:
Endocrine:
Hematologic/Lymphatic/Immune:
**Part II: Focused Physical Examination (Objective Data Only)**
**Physical Examination: Objective Data Only (Do NOT include subjective statements):**
General:
Skin:
Head:
Eyes:
Ears:
Nose:
Mouth/Throat:
Neck:
Cardiac:
Lungs:
Abdomen:
Genitourinary (GU):
Musculoskeletal:
Lower Extremities:
Neurologic:
**Part III: Assessment and Diagnostic Reasoning**
**Part III, Section 1: Three Differential Diagnoses**
**Directions:** Using the template below, for each differential diagnosis, provide pathophysiologic explanation, identify pertinent positives, identify pertinent negatives, explain why it is ruled in or ruled out.
**Differential Diagnosis #1:**
Condition:
Rationale:
Pertinent positives and negatives:
**Differential Diagnosis #2:**
Condition:
Rationale:
Pertinent positives and negatives:
**Differential Diagnosis #3:**
Condition:
Rationale:
Pertinent positives and negatives:
**Part III, Section 2: One Primary Diagnosis**
**Directions:** Indicate your final diagnosis (
**ONE** ONLY). Include your diagnostic reasoning with rationale: provide clear clinical justification, correlate subjective and objective findings, and explain why competing diagnoses are less likely.
**Part III, Section 3: Final Problem Statement**
**Directions:** Use the template below to write a final, synthesized problem statement.
[Initials/Name], [Age], presents with [chief complaint] characterized by [positive subjective findings] and denies [negative subjective findings]. Physical exam reveals [positive objective findings] with absence of [negative objective findings]. Pertinent history includes [relevant PMH, family history, or risk factors]. The overall clinical picture is most consistent with [final diagnosis].
**Part IV: Reflection**
This reflection is designed to strengthen your clinical reasoning and your ability to clearly separate subjective and objective data in documentation.
**Part IV, Section 1: Subjective vs. Objective Distinction**
1. Identify one example in your documentation where it was challenging to separate subjective and objective data.
2. Explain how you ensured patient-reported symptoms remained in the history/ROS and observable findings remained in the physical exam.
3. Briefly explain why this distinction is important for diagnostic accuracy.
**Part IV, Section 2: Diagnostic Reasoning**
1. Identify one differential diagnosis you strongly considered but ultimately ruled out.
2. List
**two** key findings (pertinent positives or negatives) that helped you rule it out.
3. State what finding most strongly supported your final diagnosis.
**References**
List 3–5 peer-reviewed references, less than 5 Years Old. Cite all sources in APA format.
**## NURS_6512_M3AS2_Assignment_Template.docx**
**NURS 6512**
**Week 7 Assignment Template**
**Comprehensive Health History, Physical Examination, and Assessment Template**
**Part I: Comprehensive Health History (Subjective Data Only)**
**Subjective Data**
Chief Complaint (CC):
History of Present Illness (HPI):
Past Medical History (PMH):
Surgical History (PSH):
Medications:
Allergies:
Preventive Health:
Social History:
**Review of Systems (ROS) (Subjective Data Only – Patient-Reported Symptoms):**
General:
Skin:
HEENT:
Cardiac:
Respiratory:
Gastrointestinal (GI):
Genitourinary (GU):
Musculoskeletal (MSK):
Neurologic:
Psychiatric:
Endocrine:
Hematologic/Lymphatic/Immune:
**Part II: Focused Physical Examination (Objective Data Only)**
**Physical Examination: Objective Data Only (Do NOT include subjective statements):**
General:
Skin:
Head:
Eyes:
Ears:
Nose:
Mouth/Throat:
Neck:
Cardiac:
Lungs:
Abdomen:
Genitourinary (GU):
Musculoskeletal:
Lower Extremities:
Neurologic:
**Part III: Assessment and Diagnostic Reasoning**
**Part III, Section 1: Three Differential Diagnoses**
**Directions:** Using the template below, for each differential diagnosis, provide pathophysiologic explanation, identify pertinent positives, identify pertinent negatives, explain why it is ruled in or ruled out.
**Differential Diagnosis #1:**
Condition:
Rationale:
Pertinent positives and negatives:
**Differential Diagnosis #2:**
Condition:
Rationale:
Pertinent positives and negatives:
**Differential Diagnosis #3:**
Condition:
Rationale:
Pertinent positives and negatives:
**Part III, Section 2: One Primary Diagnosis**
**Directions:** Indicate your final diagnosis (
**ONE** ONLY). Include your diagnostic reasoning with rationale: provide clear clinical justification, correlate subjective and objective findings, and explain why competing diagnoses are less likely.
**Part III, Section 3: Final Problem Statement**
**Directions:** Use the template below to write a final, synthesized problem statement.
[Initials/Name], [Age], presents with [chief complaint] characterized by [positive subjective findings] and denies [negative subjective findings]. Physical exam reveals [positive objective findings] with absence of [negative objective findings]. Pertinent history includes [relevant PMH, family history, or risk factors]. The overall clinical picture is most consistent with [final diagnosis].
**Part IV: Reflection**
This reflection is designed to strengthen your clinical reasoning and your ability to clearly separate subjective and objective data in documentation.
**Part IV, Section 1: Subjective vs. Objective Distinction**
1. Identify one example in your documentation where it was challenging to separate subjective and objective data.
2. Explain how you ensured patient-reported symptoms remained in the history/ROS and observable findings remained in the physical exam.
3. Briefly explain why this distinction is important for diagnostic accuracy.
**Part IV, Section 2: Diagnostic Reasoning**
1. Identify one differential diagnosis you strongly considered but ultimately ruled out.
2. List
**two** key findings (pertinent positives or negatives) that helped you rule it out.
3. State what finding most strongly supported your final diagnosis.
**References**
List 3–5 peer-reviewed references, less than 5 Years Old. Cite all sources in APA format.
**## SimulationcasestudyModul3.docx**
**Simulation Case Studies -Burning In Chest After Eating**
**Burning in Chest After Eating Presentation**
**Angela Brooks**
**Age:** 52
**Sex:** Female
**Race/Ethnicity:** African American
**Marital Status:** Divorced
**Occupation:** Real Estate Agent
**Insurance:** Private
**Living Situation:** Lives alone
**Chief Complaint (CC):** Burning in Chest After Eating
**Patient Statement**
For about the past three or four months, I’ve been getting this burning feeling in the middle of my chest after I eat. It usually starts about 30 minutes to an hour after meals, especially if I eat something spicy or fried. Sometimes it feels like the food is coming back up into my throat, and I get a sour taste in my mouth.
It’s not really a sharp pain — more like a burning pressure. I’d rate it about a 5 out of 10. It’s worse when I lie down at night, and I’ve had to prop myself up on pillows. I’ve also noticed I clear my throat a lot in the mornings.
I haven’t had shortness of breath. No sweating. No pain going into my arm or jaw. I haven’t thrown up, and I haven’t seen any blood. My weight has been stable.
I drink coffee every morning and usually have a glass of wine a few nights a week. I’ve been under some stress lately and probably eat out more than I should. I’ve been taking over-the-counter antacids, and they help, but the symptoms keep coming back.
© 2026 Walden University, LLC
## image1.jpeg
**## NURS_6512_Assessment_ReferenceSheet.pdf**
NURS 6512: Assessment Reference Sheet
Purpose
To guide you in writing a clear, logical Assessment, including differential diagnoses, one final
diagnosis supported by evidence, and required references supporting clinical reasoning.
Overview of Expectations
– Include 3–5 differential diagnoses.
– Select ONE final diagnosis.
– Support all reasoning with subjective and objective findings.
– Use professional, concise clinical language.
– Include 3–5 peer-reviewed references (≤5 years old) to support diagnostic reasoning.
Differential Diagnoses (3–5 Required)
Differential #1
Condition:
Rationale:
Subjective findings (supporting):
–
Subjective findings (non-supporting/absent):
–
Objective findings (supporting):
–
Objective findings (non-supporting/absent):
–
Differential #2
Condition:
Rationale:
Subjective findings (supporting):
–
Subjective findings (non-supporting/absent):
–
Objective findings (supporting):
–
Objective findings (non-supporting/absent):
–
Differential #3
Condition:
Rationale:
Subjective findings (supporting):
–
Subjective findings (non-supporting/absent):
–
Objective findings (supporting):
–
Objective findings (non-supporting/absent):
–
Differential #4 (Optional)
Differential #5 (Optional)
Final Diagnosis (ONE ONLY)
Final Diagnosis: [Write the final diagnosis here]
Final Problem Statement Template
[Initials/Name], [Age], presents with [chief complaint] characterized by [positive subjective
findings] and denies [negative subjective findings]. Physical exam reveals [positive objective
findings] with absence of [negative objective findings]. Pertinent history includes [relevant PMH,
family history, or risk factors]. The overall clinical picture is most consistent with [final diagnosis].
Reference Requirements
You must include 3–5 peer-reviewed journal references (published within the last 5 years) to
support diagnostic reasoning in the Assessment. References must:
– Align with the differential diagnoses and/or final diagnosis.
– Support pathophysiology, clinical presentation, or diagnostic criteria.
– Be cited in APA 7th edition format.
– Not include textbooks, blogs, or patient-education websites.
Example acceptable sources:
– Peer-reviewed journal articles
– Clinical practice guidelines (ACC/AHA, ADA, IDSA, AAP, USPSTF)
– Systematic reviews or meta-analyses
**## NURS_6512_PhysicalExamination_ReferenceSheet.pdf**
NURS 6512: Physical Examination Reference Sheet
NURS 6512 – Advanced Health Assessment & Diagnostic Reasoning
Purpose: To guide students in documenting objective findings only during the physical
examination.
REMINDER: PHYSICAL EXAM = OBJECTIVE DATA ONLY
This section should include only what you observe, measure, or assess — not what the patient
reports. Do NOT include subjective statements or history.
✅ Correct (Objective): “Lungs clear to auscultation bilaterally; no wheezes, rales, or rhonchi.”
❌ Incorrect (Subjective): “Patient reports shortness of breath and chest tightness.”
GENERAL FORMAT FOR PHYSICAL EXAM DOCUMENTATION
• General: Appearance, distress, hygiene, orientation
• Skin: Color, temperature, turgor, lesions, rashes
• Head: Normocephalic, atraumatic
• Eyes: PERRLA, EOMI, conjunctiva clear
• Ears: TM intact, no erythema or effusion
• Nose: Mucosa pink, septum midline, no discharge
• Mouth/Throat: Mucosa moist, no erythema or exudate
• Neck: Supple, no lymphadenopathy, thyroid non-enlarged
• Cardiac: RRR, no murmurs, rubs, or gallops
• Lungs: CTA bilaterally, no wheezes, rales, or rhonchi
• Abdomen: Contour, bowel sounds, tenderness, organomegaly
• GU: External genitalia, discharge, lesions, CVA tenderness (as indicated)
• Musculoskeletal: ROM, strength, gait, deformities, tenderness
• Lower Extremities: Edema, pulses, color, warmth, capillary refill, sensation
• Neuro: CN II–XII grossly intact, strength and sensation symmetrical
Chief Complaint, Must-Not-Miss Diagnoses, and Systems to Examine
Identify high-priority conditions and focus your exam to rule them out.
Chief Complaint Must-Not-Miss Diagnoses Systems to Examine
Cough or Shortness of
Breath
Pneumonia, Pulmonary
embolism, Myocardial
infarction, Heart failure,
Pneumothorax
Respiratory, Cardiac, ENT,
Skin (cyanosis), Lower
Extremities (edema/DVT
signs)
Abdominal Pain Appendicitis, Bowel
obstruction, Perforated
Abdomen, GU, Cardiac,
Respiratory, Skin
ulcer, Ectopic pregnancy,
Cholecystitis, Pancreatitis
(jaundice), Neuro (pain
localization)
Headache Subarachnoid hemorrhage,
Meningitis, Temporal
arteritis, Intracranial mass,
Hypertensive emergency,
CVA (stroke)
Neuro, HEENT, Neck, Eyes
(fundoscopic), Cardiac (BP),
Skin (rash/meningitis)
Back Pain Cauda equina syndrome,
Epidural abscess, Spinal
fracture, Pyelonephritis,
Abdominal aortic aneurysm
(AAA)
Musculoskeletal, Neuro,
Abdomen, GU (CVA
tenderness), Skin
(infection)
UTI Symptoms Pyelonephritis, Urosepsis,
Pregnancy, Obstructive
uropathy
Abdomen, GU, CVA
tenderness, Skin (fever
signs), Neuro (confusion in
elderly)
Sore Throat Peritonsillar abscess,
Epiglottitis, Mononucleosis,
Streptococcal pharyngitis
HEENT, Lymphatic, Neck,
Cardiac, Respiratory
(airway), Skin
(rash/scarlatina)
Rash Cellulitis, Meningococcemia,
Stevens-Johnson syndrome,
Drug reaction, Anaphylaxis
Skin, Lymphatic, HEENT
(mucosal lesions),
Respiratory (distress),
Cardiac (shock signs)
Extremity/Joint Pain DVT, Septic joint, Fracture,
Cellulitis, Compartment
syndrome
Musculoskeletal, Neuro,
Lower Extremities (pulses,
edema, warmth, sensation),
Skin
DOCUMENTATION TIP
• Use head-to-toe format only for comprehensive exams (annuals, new patient, baseline).
• Use focused format for problem-based visits.
• Objective findings should align with your assessment and must-not-miss differential diagnoses.
**## NURS_6512_ComprehensiveHealthHistory_ReferenceSheet1.pdf**
NURS 6512: Comprehensive Health History Reference Sheet
⚠ Reminder: The health history includes **subjective data only** — information
provided by the patient about their symptoms, perceptions, and experiences.
Objective findings belong in the physical exam section.
Chief Complaint (CC)
• State the patient’s main reason for visit — concise and focused.
• Use the patient’s own words in quotes (1–2 words or one short sentence).
• Example: “Sore throat for two days.” or “Shortness of breath.”
History of Present Illness (HPI) – OLDCARTS + Pertinent History
• Use OLDCARTS to gather data, then synthesize into a cohesive paragraph written
in complete sentences.
• Avoid bullet points. Tell the story of the symptom(s) using the data you collected.
• O – Onset: When did it start?
• L – Location: Where is it? Does it radiate?
• D – Duration: Constant or intermittent?
• C – Character: Describe the quality (sharp, dull, throbbing).
• A – Aggravating factors: What makes it worse?
• R – Relieving factors: What makes it better?
• T – Timing: Pattern, frequency, time of day.
• S – Severity: 0–10 pain scale or functional impact.
• Include associated symptoms and pertinent negatives (important symptoms the
patient denies).
• Incorporate pertinent history such as recent illness, exposures, travel, medications
tried, previous episodes, or related chronic conditions.
• Example: The HPI should read as a full paragraph that flows logically and reflects
critical thinking — not as a list of OLDCARTS items.
Past Medical History (PMH)
• Chronic illnesses (HTN, DM, asthma, etc.)
• Childhood illnesses (if relevant)
• Hospitalizations and psychiatric history
Surgical History (PSH)
• List all surgeries/procedures with year, indication, and complications
Medications
• List all: prescription, OTC, herbal, and supplements
• Include name, dose, route, frequency, indication
• Note adherence and side effects
Allergies
• Drug, food, environmental — include reaction type (rash, anaphylaxis, etc.)
• Document tolerated alternatives if known
Preventive Health
• Immunizations: Flu, COVID-19, Tdap, shingles, pneumococcal
• Screenings: Pap, mammogram, colonoscopy, lipid, glucose, DEXA
• Risk factors: Diet, exercise, safety, sexual health, sleep, stress, dental, vision
Social History
• Tobacco: Type, amount, duration, quit attempts
• Alcohol: Type, frequency, quantity (CAGE if indicated)
• Substance use: Illicit or prescription misuse
• Occupation: Exposures, stress, satisfaction
• Living situation & support system
• Safety: IPV, firearms, seatbelt use
• Social Determinants of Health (SDOH): Housing, food, transport, access, finances
Review of Systems (ROS)
These are subjective symptoms that the patient reports. No objective exam findings
should be included here.
• General: Fever, chills, weight change, fatigue
• Skin: Rashes, lesions, itching
• HEENT: Vision, hearing, congestion, sore throat
• Cardiac: Chest pain, palpitations, edema
• Respiratory: Cough, SOB, wheezing
• GI: N/V/D, constipation, pain, appetite
• GU: Dysuria, frequency, hematuria
• MSK: Joint pain, stiffness, weakness
• Neuro: Headache, dizziness, numbness, seizures
• Psych: Mood, anxiety, sleep
• Endo: Heat/cold intolerance, polyuria/polydipsia
• Heme: Easy bruising/bleeding
**## NURS_6512_M3AS2_Assignment_Template.docx**
**NURS 6512**
**Week 7 Assignment Template**
**Comprehensive Health History, Physical Examination, and Assessment Template**
**Part I: Comprehensive Health History (Subjective Data Only)**
**Subjective Data**
Chief Complaint (CC):
History of Present Illness (HPI):
Past Medical History (PMH):
Surgical History (PSH):
Medications:
Allergies:
Preventive Health:
Social History:
**Review of Systems (ROS) (Subjective Data Only – Patient-Reported Symptoms):**
General:
Skin:
HEENT:
Cardiac:
Respiratory:
Gastrointestinal (GI):
Genitourinary (GU):
Musculoskeletal (MSK):
Neurologic:
Psychiatric:
Endocrine:
Hematologic/Lymphatic/Immune:
**Part II: Focused Physical Examination (Objective Data Only)**
**Physical Examination: Objective Data Only (Do NOT include subjective statements):**
General:
Skin:
Head:
Eyes:
Ears:
Nose:
Mouth/Throat:
Neck:
Cardiac:
Lungs:
Abdomen:
Genitourinary (GU):
Musculoskeletal:
Lower Extremities:
Neurologic:
**Part III: Assessment and Diagnostic Reasoning**
**Part III, Section 1: Three Differential Diagnoses**
**Directions:** Using the template below, for each differential diagnosis, provide pathophysiologic explanation, identify pertinent positives, identify pertinent negatives, explain why it is ruled in or ruled out.
**Differential Diagnosis #1:**
Condition:
Rationale:
Pertinent positives and negatives:
**Differential Diagnosis #2:**
Condition:
Rationale:
Pertinent positives and negatives:
**Differential Diagnosis #3:**
Condition:
Rationale:
Pertinent positives and negatives:
**Part III, Section 2: One Primary Diagnosis**
**Directions:** Indicate your final diagnosis (
**ONE** ONLY). Include your diagnostic reasoning with rationale: provide clear clinical justification, correlate subjective and objective findings, and explain why competing diagnoses are less likely.
**Part III, Section 3: Final Problem Statement**
**Directions:** Use the template below to write a final, synthesized problem statement.
[Initials/Name], [Age], presents with [chief complaint] characterized by [positive subjective findings] and denies [negative subjective findings]. Physical exam reveals [positive objective findings] with absence of [negative objective findings]. Pertinent history includes [relevant PMH, family history, or risk factors]. The overall clinical picture is most consistent with [final diagnosis].
**Part IV: Reflection**
This reflection is designed to strengthen your clinical reasoning and your ability to clearly separate subjective and objective data in documentation.
**Part IV, Section 1: Subjective vs. Objective Distinction**
1. Identify one example in your documentation where it was challenging to separate subjective and objective data.
2. Explain how you ensured patient-reported symptoms remained in the history/ROS and observable findings remained in the physical exam.
3. Briefly explain why this distinction is important for diagnostic accuracy.
**Part IV, Section 2: Diagnostic Reasoning**
1. Identify one differential diagnosis you strongly considered but ultimately ruled out.
2. List
**two** key findings (pertinent positives or negatives) that helped you rule it out.
3. State what finding most strongly supported your final diagnosis.
**References**
List 3–5 peer-reviewed references, less than 5 Years Old. Cite all sources in APA format.
**## SimulationcasestudyModul3.docx**
**Simulation Case Studies -Burning In Chest After Eating**
**Burning in Chest After Eating Presentation**
**Angela Brooks**
**Age:** 52
**Sex:** Female
**Race/Ethnicity:** African American
**Marital Status:** Divorced
**Occupation:** Real Estate Agent
**Insurance:** Private
**Living Situation:** Lives alone
**Chief Complaint (CC):** Burning in Chest After Eating
**Patient Statement**
For about the past three or four months, I’ve been getting this burning feeling in the middle of my chest after I eat. It usually starts about 30 minutes to an hour after meals, especially if I eat something spicy or fried. Sometimes it feels like the food is coming back up into my throat, and I get a sour taste in my mouth.
It’s not really a sharp pain — more like a burning pressure. I’d rate it about a 5 out of 10. It’s worse when I lie down at night, and I’ve had to prop myself up on pillows. I’ve also noticed I clear my throat a lot in the mornings.
I haven’t had shortness of breath. No sweating. No pain going into my arm or jaw. I haven’t thrown up, and I haven’t seen any blood. My weight has been stable.
I drink coffee every morning and usually have a glass of wine a few nights a week. I’ve been under some stress lately and probably eat out more than I should. I’ve been taking over-the-counter antacids, and they help, but the symptoms keep coming back.
© 2026 Walden University, LLC
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**## NURS_6512_Assessment_ReferenceSheet.pdf**
NURS 6512: Assessment Reference Sheet
Purpose
To guide you in writing a clear, logical Assessment, including differential diagnoses, one final
diagnosis supported by evidence, and required references supporting clinical reasoning.
Overview of Expectations
– Include 3–5 differential diagnoses.
– Select ONE final diagnosis.
– Support all reasoning with subjective and objective findings.
– Use professional, concise clinical language.
– Include 3–5 peer-reviewed references (≤5 years old) to support diagnostic reasoning.
Differential Diagnoses (3–5 Required)
Differential #1
Condition:
Rationale:
Subjective findings (supporting):
–
Subjective findings (non-supporting/absent):
–
Objective findings (supporting):
–
Objective findings (non-supporting/absent):
–
Differential #2
Condition:
Rationale:
Subjective findings (supporting):
–
Subjective findings (non-supporting/absent):
–
Objective findings (supporting):
–
Objective findings (non-supporting/absent):
–
Differential #3
Condition:
Rationale:
Subjective findings (supporting):
–
Subjective findings (non-supporting/absent):
–
Objective findings (supporting):
–
Objective findings (non-supporting/absent):
–
Differential #4 (Optional)
Differential #5 (Optional)
Final Diagnosis (ONE ONLY)
Final Diagnosis: [Write the final diagnosis here]
Final Problem Statement Template
[Initials/Name], [Age], presents with [chief complaint] characterized by [positive subjective
findings] and denies [negative subjective findings]. Physical exam reveals [positive objective
findings] with absence of [negative objective findings]. Pertinent history includes [relevant PMH,
family history, or risk factors]. The overall clinical picture is most consistent with [final diagnosis].
Reference Requirements
You must include 3–5 peer-reviewed journal references (published within the last 5 years) to
support diagnostic reasoning in the Assessment. References must:
– Align with the differential diagnoses and/or final diagnosis.
– Support pathophysiology, clinical presentation, or diagnostic criteria.
– Be cited in APA 7th edition format.
– Not include textbooks, blogs, or patient-education websites.
Example acceptable sources:
– Peer-reviewed journal articles
– Clinical practice guidelines (ACC/AHA, ADA, IDSA, AAP, USPSTF)
– Systematic reviews or meta-analyses
**## NURS_6512_PhysicalExamination_ReferenceSheet.pdf**
NURS 6512: Physical Examination Reference Sheet
NURS 6512 – Advanced Health Assessment & Diagnostic Reasoning
Purpose: To guide students in documenting objective findings only during the physical
examination.
REMINDER: PHYSICAL EXAM = OBJECTIVE DATA ONLY
This section should include only what you observe, measure, or assess — not what the patient
reports. Do NOT include subjective statements or history.
✅ Correct (Objective): “Lungs clear to auscultation bilaterally; no wheezes, rales, or rhonchi.”
❌ Incorrect (Subjective): “Patient reports shortness of breath and chest tightness.”
GENERAL FORMAT FOR PHYSICAL EXAM DOCUMENTATION
• General: Appearance, distress, hygiene, orientation
• Skin: Color, temperature, turgor, lesions, rashes
• Head: Normocephalic, atraumatic
• Eyes: PERRLA, EOMI, conjunctiva clear
• Ears: TM intact, no erythema or effusion
• Nose: Mucosa pink, septum midline, no discharge
• Mouth/Throat: Mucosa moist, no erythema or exudate
• Neck: Supple, no lymphadenopathy, thyroid non-enlarged
• Cardiac: RRR, no murmurs, rubs, or gallops
• Lungs: CTA bilaterally, no wheezes, rales, or rhonchi
• Abdomen: Contour, bowel sounds, tenderness, organomegaly
• GU: External genitalia, discharge, lesions, CVA tenderness (as indicated)
• Musculoskeletal: ROM, strength, gait, deformities, tenderness
• Lower Extremities: Edema, pulses, color, warmth, capillary refill, sensation
• Neuro: CN II–XII grossly intact, strength and sensation symmetrical
Chief Complaint, Must-Not-Miss Diagnoses, and Systems to Examine
Identify high-priority conditions and focus your exam to rule them out.
Chief Complaint Must-Not-Miss Diagnoses Systems to Examine
Cough or Shortness of
Breath
Pneumonia, Pulmonary
embolism, Myocardial
infarction, Heart failure,
Pneumothorax
Respiratory, Cardiac, ENT,
Skin (cyanosis), Lower
Extremities (edema/DVT
signs)
Abdominal Pain Appendicitis, Bowel
obstruction, Perforated
Abdomen, GU, Cardiac,
Respiratory, Skin
ulcer, Ectopic pregnancy,
Cholecystitis, Pancreatitis
(jaundice), Neuro (pain
localization)
Headache Subarachnoid hemorrhage,
Meningitis, Temporal
arteritis, Intracranial mass,
Hypertensive emergency,
CVA (stroke)
Neuro, HEENT, Neck, Eyes
(fundoscopic), Cardiac (BP),
Skin (rash/meningitis)
Back Pain Cauda equina syndrome,
Epidural abscess, Spinal
fracture, Pyelonephritis,
Abdominal aortic aneurysm
(AAA)
Musculoskeletal, Neuro,
Abdomen, GU (CVA
tenderness), Skin
(infection)
UTI Symptoms Pyelonephritis, Urosepsis,
Pregnancy, Obstructive
uropathy
Abdomen, GU, CVA
tenderness, Skin (fever
signs), Neuro (confusion in
elderly)
Sore Throat Peritonsillar abscess,
Epiglottitis, Mononucleosis,
Streptococcal pharyngitis
HEENT, Lymphatic, Neck,
Cardiac, Respiratory
(airway), Skin
(rash/scarlatina)
Rash Cellulitis, Meningococcemia,
Stevens-Johnson syndrome,
Drug reaction, Anaphylaxis
Skin, Lymphatic, HEENT
(mucosal lesions),
Respiratory (distress),
Cardiac (shock signs)
Extremity/Joint Pain DVT, Septic joint, Fracture,
Cellulitis, Compartment
syndrome
Musculoskeletal, Neuro,
Lower Extremities (pulses,
edema, warmth, sensation),
Skin
DOCUMENTATION TIP
• Use head-to-toe format only for comprehensive exams (annuals, new patient, baseline).
• Use focused format for problem-based visits.
• Objective findings should align with your assessment and must-not-miss differential diagnoses.
**## NURS_6512_ComprehensiveHealthHistory_ReferenceSheet1.pdf**
NURS 6512: Comprehensive Health History Reference Sheet
⚠ Reminder: The health history includes **subjective data only** — information
provided by the patient about their symptoms, perceptions, and experiences.
Objective findings belong in the physical exam section.
Chief Complaint (CC)
• State the patient’s main reason for visit — concise and focused.
• Use the patient’s own words in quotes (1–2 words or one short sentence).
• Example: “Sore throat for two days.” or “Shortness of breath.”
History of Present Illness (HPI) – OLDCARTS + Pertinent History
• Use OLDCARTS to gather data, then synthesize into a cohesive paragraph written
in complete sentences.
• Avoid bullet points. Tell the story of the symptom(s) using the data you collected.
• O – Onset: When did it start?
• L – Location: Where is it? Does it radiate?
• D – Duration: Constant or intermittent?
• C – Character: Describe the quality (sharp, dull, throbbing).
• A – Aggravating factors: What makes it worse?
• R – Relieving factors: What makes it better?
• T – Timing: Pattern, frequency, time of day.
• S – Severity: 0–10 pain scale or functional impact.
• Include associated symptoms and pertinent negatives (important symptoms the
patient denies).
• Incorporate pertinent history such as recent illness, exposures, travel, medications
tried, previous episodes, or related chronic conditions.
• Example: The HPI should read as a full paragraph that flows logically and reflects
critical thinking — not as a list of OLDCARTS items.
Past Medical History (PMH)
• Chronic illnesses (HTN, DM, asthma, etc.)
• Childhood illnesses (if relevant)
• Hospitalizations and psychiatric history
Surgical History (PSH)
• List all surgeries/procedures with year, indication, and complications
Medications
• List all: prescription, OTC, herbal, and supplements
• Include name, dose, route, frequency, indication
• Note adherence and side effects
Allergies
• Drug, food, environmental — include reaction type (rash, anaphylaxis, etc.)
• Document tolerated alternatives if known
Preventive Health
• Immunizations: Flu, COVID-19, Tdap, shingles, pneumococcal
• Screenings: Pap, mammogram, colonoscopy, lipid, glucose, DEXA
• Risk factors: Diet, exercise, safety, sexual health, sleep, stress, dental, vision
Social History
• Tobacco: Type, amount, duration, quit attempts
• Alcohol: Type, frequency, quantity (CAGE if indicated)
• Substance use: Illicit or prescription misuse
• Occupation: Exposures, stress, satisfaction
• Living situation & support system
• Safety: IPV, firearms, seatbelt use
• Social Determinants of Health (SDOH): Housing, food, transport, access, finances
Review of Systems (ROS)
These are subjective symptoms that the patient reports. No objective exam findings
should be included here.
• General: Fever, chills, weight change, fatigue
• Skin: Rashes, lesions, itching
• HEENT: Vision, hearing, congestion, sore throat
• Cardiac: Chest pain, palpitations, edema
• Respiratory: Cough, SOB, wheezing
• GI: N/V/D, constipation, pain, appetite
• GU: Dysuria, frequency, hematuria
• MSK: Joint pain, stiffness, weakness
• Neuro: Headache, dizziness, numbness, seizures
• Psych: Mood, anxiety, sleep
• Endo: Heat/cold intolerance, polyuria/polydipsia
• Heme: Easy bruising/bleeding
**## NURS_6512_M3AS2_Assignment_Template.docx**
**NURS 6512**
**Week 7 Assignment Template**
**Comprehensive Health History, Physical Examination, and Assessment Template**
**Part I: Comprehensive Health History (Subjective Data Only)**
**Subjective Data**
Chief Complaint (CC):
History of Present Illness (HPI):
Past Medical History (PMH):
Surgical History (PSH):
Medications:
Allergies:
Preventive Health:
Social History:
**Review of Systems (ROS) (Subjective Data Only – Patient-Reported Symptoms):**
General:
Skin:
HEENT:
Cardiac:
Respiratory:
Gastrointestinal (GI):
Genitourinary (GU):
Musculoskeletal (MSK):
Neurologic:
Psychiatric:
Endocrine:
Hematologic/Lymphatic/Immune:
**Part II: Focused Physical Examination (Objective Data Only)**
**Physical Examination: Objective Data Only (Do NOT include subjective statements):**
General:
Skin:
Head:
Eyes:
Ears:
Nose:
Mouth/Throat:
Neck:
Cardiac:
Lungs:
Abdomen:
Genitourinary (GU):
Musculoskeletal:
Lower Extremities:
Neurologic:
**Part III: Assessment and Diagnostic Reasoning**
**Part III, Section 1: Three Differential Diagnoses**
**Directions:** Using the template below, for each differential diagnosis, provide pathophysiologic explanation, identify pertinent positives, identify pertinent negatives, explain why it is ruled in or ruled out.
**Differential Diagnosis #1:**
Condition:
Rationale:
Pertinent positives and negatives:
**Differential Diagnosis #2:**
Condition:
Rationale:
Pertinent positives and negatives:
**Differential Diagnosis #3:**
Condition:
Rationale:
Pertinent positives and negatives:
**Part III, Section 2: One Primary Diagnosis**
**Directions:** Indicate your final diagnosis (
**ONE** ONLY). Include your diagnostic reasoning with rationale: provide clear clinical justification, correlate subjective and objective findings, and explain why competing diagnoses are less likely.
**Part III, Section 3: Final Problem Statement**
**Directions:** Use the template below to write a final, synthesized problem statement.
[Initials/Name], [Age], presents with [chief complaint] characterized by [positive subjective findings] and denies [negative subjective findings]. Physical exam reveals [positive objective findings] with absence of [negative objective findings]. Pertinent history includes [relevant PMH, family history, or risk factors]. The overall clinical picture is most consistent with [final diagnosis].
**Part IV: Reflection**
This reflection is designed to strengthen your clinical reasoning and your ability to clearly separate subjective and objective data in documentation.
**Part IV, Section 1: Subjective vs. Objective Distinction**
1. Identify one example in your documentation where it was challenging to separate subjective and objective data.
2. Explain how you ensured patient-reported symptoms remained in the history/ROS and observable findings remained in the physical exam.
3. Briefly explain why this distinction is important for diagnostic accuracy.
**Part IV, Section 2: Diagnostic Reasoning**
1. Identify one differential diagnosis you strongly considered but ultimately ruled out.
2. List
**two** key findings (pertinent positives or negatives) that helped you rule it out.
3. State what finding most strongly supported your final diagnosis.
**References**
List 3–5 peer-reviewed references, less than 5 Years Old. Cite all sources in APA format.