Wilkes University
Passan School of Nursing
NSG 550: Diagnostic Reasoning for Nurse Practitioners
Clinical Note Guidelines
Each student will complete a clinical note utilizing the framework of a comprehensive health history and physical examination. The written assignment is documentation of the findings and should demonstrate application of course content and follow the criteria provided below. This should be in a charting format and no longer than 3 pages, excluding a title and reference page. Five points will be deducted for assignments longer than the stated criteria. APA not required so single spacing is allowed. Mastering succinctness of communication, both written and verbal of clinical reasoning, is critical to the process of becoming a nurse practitioner.
Content
Grade Percentage
Choose a patient to perform the H and P; this person could be a family member or patient from your clinical practice.
Only use initials when identifying the patient.
5%
Chief Complaint and History of Present Illness
5%
Past Medical and Surgical History
5%
Medications and Allergies
5 %
Family History
5%
Social History
5%
Review of Systems (subjective-complete review of systems including pertinent positive and negative findings as per the patient-what did the patient say)
15%
Physical Examination (objective-complete PE including pertinent positive and negative PE findings).
15%
Assessment and Plan (You can make one section with the Assessment/Plan or you can keep them as separate sections).
Provide all possible diagnoses based upon clinical decision making listing the one with the highest probability first.
Provide comprehensive treatment plan and communicate clinical reasoning; utilize theory from NSG500, 550, 530, and 533. Provide clinical support/citations.
35%
Provides references of peer reviewed, scholarly citations
5%
Total
100%
Criteria for this written assignment can be found on the next page. This information was introduced in NSG 500.
History—Subjective Data
ID
Age, gender, DOB
CC
Reason for seeking care-patient’s own words
HPI
O-onset
L-location
D-duration
C-character
A-aggravating/associated factors
R-relieving factors
T-temporal factors
S-severity
Medications, treatments
PMH/PSH
General health, surgeries, hospitalizations, illnesses, immunizations, medications, allergies, blood transfusions, emotional status/psychiatric history
Personal History
Cultural background, marital status, occupation, economic resources, environment
Health Habits
Tobacco, alcohol, illicit drugs, lifestyle, diet, exercise, exposure to toxins
Health Maintenance
Last PE; diagnostic tests (date, result, follow-up); self-exams (breast, genital, testicular); last Pap smear, mammogram
Family History
(Parents, siblings, children)
Cancer, DM, hypertension, heart disease, stroke
REVIEW OF SYSTEMS
General
Fever, chills, malaise, fatigue/energy, night sweats, desired weight
Diet
Appetite, restrictions, vitamins, supplements
Skin, Hair, Nails
Rash, eruptions, itching, pigment changes
Head and Neck
Headaches, dizziness, head injuries, loss of consciousness
Eyes
Blurring, double vision, visual changes, glasses, trauma, eye diseases
Ears
Hearing loss, pain, discharge, vertigo, tinnitus
Nose
Congestion, nosebleeds, postnasal drip
Throat and Mouth
Hoarseness, sore throat, bleeding gums, ulcers, tooth problems
Gastrointestinal
Indigestion, heartburn, vomiting, bowel regularity/changes
Lymph
Tenderness, enlargement
Endocrine
Heat/cold intolerance, weight change, polydipsia, polyuria, hair changes, increased hat, glove, or shoe size
Female
LMP, age at menarche, gravity, parity, menses (onset, regularity, duration, symptoms), sexual life (number of partners, satisfaction), contraception, menopause (age, symptoms)
Male
Puberty onset, erections, testicular pain, libido, infertility
Breasts
Pain, tenderness, lumps, discharge
Chest and Lungs
Cough, sputum, shortness of breath, dyspnea on exertion, night sweats, exposure to TB
Cardiovascular
Chest pain, palpitations, number of pillows, edema, claudication, exercise tolerance
Hematology
Anemia, easy bruising
Genitourinary
Dysuria, flank pain, urgency, frequency, nocturia, hematuria, dribbling
Musculoskeletal
Joint pain, heat swelling
Neurologic
Fainting, weakness, loss of coordination
Mental Status
Concentration, sleeping, eating, socialization, mood changes, suicidal thoughts
Physical Examination—Objective Data
VS
TPR, BP, Ht, Wt, BMI, Pulse Ox
General Appearance
Age, race, gender, posture and gait
Mental Status
Consciousness, cognitive ability, memory, emotional stability, thought content, speech quality
Skin
Color, integrity, hygiene, turgor, hydration, edema, lesions, hair distribution and texture, nail texture, nail base angle
Head
Scalp, temporal arteries, deformities
Neck
Trachea (position, tug), range of motion (ROM), carotid bruit, jugular venous distention (JVD), thyroid, lymph (head and neck)
Eyes
Pupils (PERRLA), eyelids, conjunctivae, sclerae, EOMs (CN III, IV, VI), light reflex, visual fields, funduscopy (CN II), acuity (CN II), nystagmus
Ears
Deformities, lesions, discharge, otoscopy (canal, TM), hearing (Rinne, Weber, CN VIII)
Nose
Mucosa, septum, turbinates, discharge, sinus area swelling or tenderness
Mouth and Throat
Lips/teeth/gums, tongue (CN XII), mucosa, palates, tonsils, exudate, uvula, gag reflex (CN IX, X)
Chest/Lungs
Shape, movement, respirations (rate, rhythm), expansion, accessory muscles, tactile fremitus, crepitus, percussion tone, excursion, auscultation (clear, wheeze, crackles, rhonchi, rubs)
Breasts
Contour, symmetry, nipples, areolae, discharge, lumps/masses, lymph (axillary, supraclavicular, and infraclavicular)
Heart
PMI, lifts, thrills, rate, rhythm, S1, S2, splitting, gallops, rubs, murmurs, snaps
Blood Vessels
Cyanosis, clubbing, edema, peripheral pulses, skin, nails
Abdomen
Contour, symmetry, skin, bowel sounds, bruits, hum, liver span, liver border, tenderness, masses, spleen, kidneys, aortic pulsation, reflexes, percussion tone, costovertebral angle (CVA) tenderness, femoral pulses, lymph (inguinal)
Male Genitalia
Pubic hair, glans, penis, testis, scrotum, epididymis, urethral discharge, hernias
Female Genitalia
External lesions or discharge, Bartholin and Skene glands, urethra, vaginal walls, cervix (position, lesions, cervical motion tenderness), uterus, adnexa
Rectum/Prostate
Sacrococcygeal and perineal areas, anus, sphincter tone, rectal walls, masses, fecal occult blood test (FOBT)
Male: Prostate
Female: Rectovaginal septum, uterus
Musculoskeletal
Posture, alignment, symmetry, joint heat/swelling/color, muscle tone, ROM, strength
Neurologic
CN II-XII, rapid alternating movements, finger-to-nose, sensation, vibration, stereognosis, motor system, gait, Romberg, deep tendon reflexes (DTRs), superficial reflexes
Cranial Nerves
I: Smell
II: Visual acuity, visual fields, funduscopy
III, IV, VI: Eyelid opening EOMs: IV up and out, VI lateral, III all others
V: Corneal reflex, facial sensation (3 areas), jaw opening, bite strength
VII: Eyebrow raise, eyelid close, smile, taste
VIII: Rinne, Weber
IX, X: Gag reflex, palate elevation, phonation
XI: Lateral head rotation, neck flexion, shoulder shrug
XII: Tongue protrusion, lateral deviation strength
Assessment
Diagnosis(es)-clinical reasoning
Plan
Treatment; rationale
That is an example:
Tension Headache Management Plan
Patient Information
Initials: J.D
Age/gender:45/male
Date of birth:01.05.1978
Chief Complaint:
“I have had persistent headaches for the last fourteen days.”
HPI
Onset: The patient previously had gentle migraines around fourteen days prior; however, the seriousness expanded in the past couple of days.
Location: Agony stringently to the front-facing region; however, it can, at times, spread to the transient locales.
Duration: The migraines are ongoing and vanish completely at no point during the day, with in the middle between.
Character: Portrayed by a throbbing impression that deteriorates when presented to light or commotion sources.
Aggravating Variables: Stress at work and extended periods utilizing PCs have been distinguished as inclining factors toward cerebral pains.
Relieving Variables: The patient can help solace through rest and taking common Ibuprofen bought without a remedy.
Severity: Marked 6/10 on the intensity scale with a high of 8/10 during periods of highly stressful conditions.
Past Medical and Surgical History (PMH/PSH).
General Health: No long-term illnesses, serious disorders, or significant diseases in the past.
Surgeries: The patient underwent an appendectomy at the age of 22 years. No complications or residual effects.
Hospitalization: None reported
Immunizations: Updated, including seasonal flu vaccines.
Allergies: This patient has a penicillin allergy, resulting in skin rush.
Medication
Current Medications: Ibuprofen need for head relief not exceeding 1200 mg/day
Family History
Mother: Diagnosed with hypertension, which has been managed by medication.
Father: Has Type 2 diabetes mellitus treated with diet and oral anti-diabetic medications.
Social History
Marital Status: Married. He has a spouse and two children.
Occupation: A software engineer. He spends many hours in front of the screen.
Tobacco/Alcohol Use: Does not smoke; consumes alcohol occasionally, about once a week or once in two weeks.
Diet/Exercise: Partially adheres to guidelines with a good intake of vegetables and fruits but not a strict diet plan. Runs for 30 minutes at least 5 times a week.
Lifestyle: Describes a relatively uneventful work schedule with limited physical activity and short weekend camping.
Review of Systems
General: Has reported fatigue more often when headaches started to appear or occurred frequently. There has been no weight loss within the last week and no fever within the last month.
Cardiovascular: Reports no chest pain, palpitations, or edema to suggest heart failure.
Respiratory: Asthma has not been previously diagnosed; no history of shortness of breath or chronic cough.
Gastrointestinal: Perceived appetite remains intact; does not experience nausea or vomiting and has no alteration in bowel movement.
Neurologic: Experiences occasional dizziness that is accompanied by severe headaches; no history of seizures or fainting episodes.
Physical Examination
Vital Signs: BP 130/85mmHg, Heart rate 78bpm, T 98.6°F, height 6’1″, weight 185 lbs, BMI 24.4.
General Appearance: The patient is fully cooperative, well-nourished, attended clinic, and not in acute discomfort.
Head and Neck: No lesions detectable on the scalp or tender enlarged nodules in the temporal area. No swelling of the neck and no enlargement of neck nodes or jugular veins.
Eyes: Pupils are reactive to light and equal in size; visual fields extend to the confrontation level. There are no signs of inflammation as evidenced by redness or thick white discharge.
Ears/Nose/Throat: No malformations of the external ears; tympanic membranes normal with no features indicative of infection. The nasal mucosa is not congested and has a moist surface. Mucosal membranes of the oral cavity are healthy with no ulcers; no injection, erythema, or exudation was noted in the pharynx.
Cardiovascular: Heart auscultation indicates regular rate and rhythm. There are no murmurs or gallops.
Respiratory: Lungs clear to auscultation in both axillae; no wheezing, crackles, or rhonchi heard.
Neurologic: All cranial nerves from II through XII have normal function; no weakness in any of the extremities, and sensation simply by light touch is present. Two-point discrimination (finger-to-nose, heel-to-shin) is intact.
Primary Diagnosis: Tension-Type Headache (TTH). This is because the nature of the headache described by the patient was bilateral, pressure type, and non-pulsating, with no complaints of nausea or light sensitivity, thus typical of TTH (Alnaim et al., 2021).
Differential Diagnoses:
Migraine without Aura: This is considered because of the high level of headache severity and its interference with daily functioning, but the absence of nausea and hypersensitivity to certain stimuli (Pescador Ruschel; & De Jesus., 2023).
Cluster Headache: Probable in extension only because of lack of unilateral facial pain, rhinorrhea, lacrimation, and clinical course of attacks characteristic for cluster headaches.
Plan
Pharmacological:
Prescribe Amitriptyline 25mg at night for prophylactic purposes.
Use ibuprofen as needed for acute pain with no need to go beyond the recommended dosage.
Non-Pharmacological:
Advise changes to the arrangement of furniture and equipment at the workplace to address pains in the neck and shoulders.
Remind children to take frequent intervals while they are engrossed in screen activities.
Recommend relaxation procedures for daily practice like deep breathing and progressive muscle relaxation.
Follow up in two weeks to review symptoms and effectiveness of the taken procedures.
References
Alnaim, M. M., Bukhamsin, S. A., AlBurayh, Y. A., Alshadly, M. R., Almaslamani, K. W., Alatawi, W. L., Saber, M. A., Alzahrani, S. A., Alzuwayyid, A. H., Alomrani, H. H., Alamrani, A. H., Al Masoud, D. K., Alruwaili, A. N., Alghamdi, K. M., & Alkhediwi, L. M. (2021). Causes and treatment of tension headache: A review. Journal of Pharmaceutical Research International, 288-293.
Pescador Ruschel;, M. A., & De Jesus., O. (2023, February 13). Migraine headache – StatPearls – NCBI bookshelf. National Center for Biotechnology Information.
