MSN 622 Sentinel U Carl Resendez
Typical Adult Simulation Full Patient
Scenario, Assessment, Diagnosis, SOAP
Note
Overview
The Carl Resendez Typical Adult Simulation is an advanced practice primary care scenario that
evaluates the learner's ability to:
• Conduct a comprehensive patient interview
• Obtain a focused history
• Perform an appropriate physical assessment
• Develop differential diagnoses
• Order evidence-based diagnostic tests
• Interpret laboratory findings
• Formulate an appropriate treatment plan
• Educate the patient
• Document findings using SOAP format
• Reflect on clinical reasoning through debriefing
The simulation is designed to strengthen clinical judgment and diagnostic reasoning in an adult
primary care setting.
Learning Objectives
After completing this simulation, students should be able to:
• Collect subjective and objective patient data.
• Recognize common adult health conditions.
• Develop prioritized differential diagnoses.
• Select appropriate laboratory and diagnostic studies.
• Interpret abnormal findings.
• Develop evidence-based treatment plans.
• Provide patient-centered education.
• Create complete SOAP documentation.
• Demonstrate safe clinical decision-making.
,Patient Assessment
Subjective Data
Obtain:
• Chief complaint
• History of present illness (OLDCARTS)
• Past medical history
• Surgical history
• Medications
• Allergies
• Family history
• Social history
• Review of systems
Objective Data
Perform:
• Vital signs
• General assessment
• HEENT examination
• Cardiovascular examination
• Respiratory examination
• Abdominal examination
• Neurological assessment
• Musculoskeletal assessment
• Skin examination
Differential Diagnoses
Possible diagnoses may include:
• Type 2 diabetes mellitus
• Hypothyroidism
• Iron deficiency anemia
• Depression
• Chronic fatigue syndrome
• Viral illness
• Sleep disorders
The final diagnosis should be based on the complete clinical picture rather than a single
symptom.
,Diagnostic Tests
Common evidence-based laboratory studies include:
• Complete Blood Count (CBC)
• Comprehensive Metabolic Panel (CMP)
• Hemoglobin A1C
• Urinalysis
• Lipid Panel
• Thyroid-Stimulating Hormone (TSH)
• Additional tests as clinically indicated
Clinical Decision-Making
Students should demonstrate the ability to:
• Prioritize patient problems.
• Rule out life-threatening conditions.
• Interpret laboratory abnormalities.
• Confirm the most likely diagnosis.
• Avoid diagnostic anchoring.
• Use evidence-based guidelines.
Treatment Plan
An appropriate plan should address:
• Pharmacologic therapy when indicated
• Lifestyle modification
• Nutrition counseling
• Exercise recommendations
• Weight management
• Preventive care
• Appropriate referrals
• Follow-up appointments
• Patient education
Patient Education
Discuss:
• Disease process
• Medication adherence
• Lifestyle changes
, • Nutrition
• Exercise
• Warning signs requiring medical attention
• Home monitoring
• Preventive screenings
• Importance of follow-up
SOAP Documentation
A complete SOAP note should include:
Subjective
• Chief complaint
• HPI
• ROS
• Medical history
Objective
• Physical examination
• Vital signs
• Diagnostic findings
Assessment
• Primary diagnosis
• Differential diagnoses
Plan
• Medications
• Diagnostic studies
• Education
• Referrals
• Follow-up
Clinical Competencies Evaluated
The simulation commonly assesses:
• History taking
• Physical examination
• Diagnostic reasoning
• Clinical judgment
Typical Adult Simulation Full Patient
Scenario, Assessment, Diagnosis, SOAP
Note
Overview
The Carl Resendez Typical Adult Simulation is an advanced practice primary care scenario that
evaluates the learner's ability to:
• Conduct a comprehensive patient interview
• Obtain a focused history
• Perform an appropriate physical assessment
• Develop differential diagnoses
• Order evidence-based diagnostic tests
• Interpret laboratory findings
• Formulate an appropriate treatment plan
• Educate the patient
• Document findings using SOAP format
• Reflect on clinical reasoning through debriefing
The simulation is designed to strengthen clinical judgment and diagnostic reasoning in an adult
primary care setting.
Learning Objectives
After completing this simulation, students should be able to:
• Collect subjective and objective patient data.
• Recognize common adult health conditions.
• Develop prioritized differential diagnoses.
• Select appropriate laboratory and diagnostic studies.
• Interpret abnormal findings.
• Develop evidence-based treatment plans.
• Provide patient-centered education.
• Create complete SOAP documentation.
• Demonstrate safe clinical decision-making.
,Patient Assessment
Subjective Data
Obtain:
• Chief complaint
• History of present illness (OLDCARTS)
• Past medical history
• Surgical history
• Medications
• Allergies
• Family history
• Social history
• Review of systems
Objective Data
Perform:
• Vital signs
• General assessment
• HEENT examination
• Cardiovascular examination
• Respiratory examination
• Abdominal examination
• Neurological assessment
• Musculoskeletal assessment
• Skin examination
Differential Diagnoses
Possible diagnoses may include:
• Type 2 diabetes mellitus
• Hypothyroidism
• Iron deficiency anemia
• Depression
• Chronic fatigue syndrome
• Viral illness
• Sleep disorders
The final diagnosis should be based on the complete clinical picture rather than a single
symptom.
,Diagnostic Tests
Common evidence-based laboratory studies include:
• Complete Blood Count (CBC)
• Comprehensive Metabolic Panel (CMP)
• Hemoglobin A1C
• Urinalysis
• Lipid Panel
• Thyroid-Stimulating Hormone (TSH)
• Additional tests as clinically indicated
Clinical Decision-Making
Students should demonstrate the ability to:
• Prioritize patient problems.
• Rule out life-threatening conditions.
• Interpret laboratory abnormalities.
• Confirm the most likely diagnosis.
• Avoid diagnostic anchoring.
• Use evidence-based guidelines.
Treatment Plan
An appropriate plan should address:
• Pharmacologic therapy when indicated
• Lifestyle modification
• Nutrition counseling
• Exercise recommendations
• Weight management
• Preventive care
• Appropriate referrals
• Follow-up appointments
• Patient education
Patient Education
Discuss:
• Disease process
• Medication adherence
• Lifestyle changes
, • Nutrition
• Exercise
• Warning signs requiring medical attention
• Home monitoring
• Preventive screenings
• Importance of follow-up
SOAP Documentation
A complete SOAP note should include:
Subjective
• Chief complaint
• HPI
• ROS
• Medical history
Objective
• Physical examination
• Vital signs
• Diagnostic findings
Assessment
• Primary diagnosis
• Differential diagnoses
Plan
• Medications
• Diagnostic studies
• Education
• Referrals
• Follow-up
Clinical Competencies Evaluated
The simulation commonly assesses:
• History taking
• Physical examination
• Diagnostic reasoning
• Clinical judgment
