NURS 550 midterm
Differential Diagnosis - ANS-• In deciding which disease to include in the differential,
consider: - What's the most life-threatening disease the patient could have? - Could this
be a common disease presenting with unusual features? - What diseases present with
misleading symptoms? - What rare diseases could be causing these signs and
symptoms?
Develop a Complete, Framed Differential Diagnosis (Hypothesis) - ANS-• Not all
diagnoses in a given differential are: - equally likely - equally important
• You must select: - a leading (working) hypothesis - a must not miss hypothesis - An
active alternative hypothesis
SOAP stands for: - ANS-• Subjective • Objective • Assessment • Plan
Subjective - ANS-The subjective section is what the patient tells you about their current
condition and past conditions.
Chief Complaint - ANS-• What brought the patient to the office
• Example: Sore throat for 2 days
History of Present Illness/Injury - ANS-- Onset - When did the symptoms and/or signs
begin, what was the mechanism of injury
- Chronology - episodic, variable, constant, etc
- Quality - sharp, dull, ache, sudden, insidious
- Severity - pain rating, 0-10 pain scale, interferes with daily activities
- Modifying factors - aggravating and alleviating factors
- Additional symptoms - unrelated or significant symptoms
- Treatment - medications, herbs, "home remedies", rest, activity, splint, etc
- Use "OLDCART" to assist you (Onset, Location, Duration, Character , Aggravating
factors, Relieving factors, Treatments"
History - ANS-Allergies - list of allergies to food, medication, and products with type of
reaction
- Medical - past and present medical conditions (i.e. asthma, hypertension, malaria,
etc.)
- Surgical - past surgeries (i.e. appendectomy, CABG, craniotomy, etc.)
,- Family - mother, father, siblings, etc. - Social - occupation, alcohol, drug, tobacco use,
risky behavior
- Immunizations - current and past received with dates
- Screenings/Health Promotion - mammography, testicular exams, dental, vision
- Review of Systems - systemic symptoms related to the current problem(s) including
pertinent positives and negatives
Review of Systems - ANS-General - fever (subjective) with chills and sweats, denies
fatigue, weakness, weight loss, or malaise
- Skin - denies rashes, lesions, discolorations
- HEENT - positive for generalized headache, sore throat, pain with swallowing and
rhinorrhea. Denies difficulty swallowing saliva, earache, sinus congestion, sinus pain,
visual or auditory aura
- Neck - denies lump, pain, stiffness, or decreased range of motion
- Cardiac - denies chest pain, pressure, tightness, palpitations
- Pulmonary - denies cough, wheeze, hemoptysis
- GI - denies nausea, vomiting, abdominal pain
- GU - denies missed menses, urinary frequency, urgency or hematuria
- MS - denies cramping, pain,
- Neuro - denies unilateral weakness, numbness, tingling
Review of Systems - ANS-• Should elaborate on the chief complaint and HPI • Don't ask
questions that the patient may not know
Review of Systems
Do you have a problem with your prostate? Do have anemia, heart failure, cancer? Do
you frequently urinate during the night? Have you noticed a change in the stream of
your urine? Do you avoid drinking fluids during work? Do you feel tired often? Are you
short of breath? Have you had any weight loss recently?
Objective - ANS-In this section you document what you observe during the examination
and visit.
Physical Examination - ANS-- Vital signs - Physical examination findings - the use of
"normal", "within normal limits", "unremarkable" and other phrases are NOT acceptable.
- Diagnostic results - Measurements including height, weight, screening tools, etc. -
Mental Status
-Weight 50 Kg previously documented height 5'3" -Vital signs - BP 118/76, HR 104, RR
16, T 38.2C, pulse Ox 99% RA -Diagnostic results •Rapid strep test positive
,-Physical examination findings - ANS-• General -Well nourished and hydrated 28 yo
female. Awake, alert and orient; appropriately dressed for season. Pleasant and
cooperative.
*Skin - hot, dry and pink. No rashes or lesions including petechiae noted
• HEENT - normocephalic, symmetric face features. No tenderness in scalp, face,
ethmoid/maxillary/frontal sinuses. Negative transillumination. External ears without
deviations, ear canal clear bilaterally, tympanic membranes pearly grey with cone of
light, bony landmarks visualized bilaterally. Nasal mucosa pink and moist turbinates with
no edema or erythema. Oral mucosa pink and moist, dentition without obvious caries;
no lesions oral cavity. Pharynx with moderate erythema tonsillar pillars ¼ bilaterally. No
exudate. Uvula midline gag reflex present.
• Neck - supple. Anterior cervical lymphadenopathy with mobile, tender nodes bilaterally
all less than 1 cm diameter. No JVD
- Cardiac - S1 S2 with no murmurs, gallops, or clicks. PMI 5th ICS mid-clavicular line
- Pulmonary - lungs clear to auscultation bilaterally in all fields. Negative tactile fremitus,
egophony, bronchophony, and whispered pectoriloquy
- GI - no masses or pulsations. Bowel sounds normoactive all 4 quadrants. No
organomegaly no bruits.
-GU- denies missed menses, urinary frequency, urgency or
hematuria
- MS - Strength 4/5 bilateral upper and lower extremities. Gait steady
- Neuro - awake, alert, and oriented to name, place, date, and surroundings. No nuchal
rigidity, Kernigs or Brudzinski signs
Assessment - ANS-This section is where the diagnosis and differential diagnosis are
listed for the date the note is written.
Sample
Diagnosis: - Strep Pharyngitis
• Differential Diagnosis:
- Viral pharyngitis
- Rheumatic fever
- Scarlet fever
Plan - ANS-This is where the treatment plan goes.
- Medications
- Diagnostic tests (i.e. laboratory, radiologic, hearing, etc.)
- Education
- Counseling
, - Referrals
- Procedures performed and the outcomes/result(s)
- Return to office date(s)/Follow up
Sample
- Amoxicillin 875mg BID for 10 days
- Rapid Strep test done in office
- Verbal instructions given on warm salt water gargles and spit 3-4 times a day; rest;
increased fluids; rest; no work 2 days note given to patient
- Patient instructed to return to the office in 2 days if no improvement. To report to the
emergency department with difficulty swallowing, breathing, rash develops, or
symptoms worse verbalized understanding.
How to Interview a Patient - ANS-Stay calm!! • Prepare before you go into the room -
Read the chart, familiarize yourself with the patient • Set an agenda - Time, needs,
issues • Look and be professional - If you look the part you have already conquered the
first hurdle
Set the Stage - ANS-• Welcome the patient using their name • Introduce yourself and
your role • Remove communication barriers - Family or professional translator • Ensure
patient privacy and comfort • Set the agenda for the visit - What are you going to do
Why is the Patient Here?
• - ANS-• Begin with open-ended questions - Requires patients to actually describe their
complaints - Obtain accurate, patient-specific information • Avoid closed-ended
questions - Similar to a long health history survey - Actually takes longer than
open-ended questions
• Be attentive while the patient is speaking - Of yourself • Silence, non-verbal
encouragement , body language -The Patient • Look for non-verbal signs and cues
• Ask question(s) and then ask again, using the patients own words • What is the
patient's personal story • Ask emotion-seeking questions
Comprehensive or Focused - ANS-Comprehensive • New patients • Identifies and rules
out physical causes related to patient concerns • Baseline • Health promotion
Focused • Established patients • Focused concerns • Symptoms of specific system(s)
Comprehensive History - ANS-• The comprehensive history is to be performed on all
non-emergent, new patients who will be receiving ongoing primary care from a
particular provider or group. • It is also expected within the hospital setting.
Differential Diagnosis - ANS-• In deciding which disease to include in the differential,
consider: - What's the most life-threatening disease the patient could have? - Could this
be a common disease presenting with unusual features? - What diseases present with
misleading symptoms? - What rare diseases could be causing these signs and
symptoms?
Develop a Complete, Framed Differential Diagnosis (Hypothesis) - ANS-• Not all
diagnoses in a given differential are: - equally likely - equally important
• You must select: - a leading (working) hypothesis - a must not miss hypothesis - An
active alternative hypothesis
SOAP stands for: - ANS-• Subjective • Objective • Assessment • Plan
Subjective - ANS-The subjective section is what the patient tells you about their current
condition and past conditions.
Chief Complaint - ANS-• What brought the patient to the office
• Example: Sore throat for 2 days
History of Present Illness/Injury - ANS-- Onset - When did the symptoms and/or signs
begin, what was the mechanism of injury
- Chronology - episodic, variable, constant, etc
- Quality - sharp, dull, ache, sudden, insidious
- Severity - pain rating, 0-10 pain scale, interferes with daily activities
- Modifying factors - aggravating and alleviating factors
- Additional symptoms - unrelated or significant symptoms
- Treatment - medications, herbs, "home remedies", rest, activity, splint, etc
- Use "OLDCART" to assist you (Onset, Location, Duration, Character , Aggravating
factors, Relieving factors, Treatments"
History - ANS-Allergies - list of allergies to food, medication, and products with type of
reaction
- Medical - past and present medical conditions (i.e. asthma, hypertension, malaria,
etc.)
- Surgical - past surgeries (i.e. appendectomy, CABG, craniotomy, etc.)
,- Family - mother, father, siblings, etc. - Social - occupation, alcohol, drug, tobacco use,
risky behavior
- Immunizations - current and past received with dates
- Screenings/Health Promotion - mammography, testicular exams, dental, vision
- Review of Systems - systemic symptoms related to the current problem(s) including
pertinent positives and negatives
Review of Systems - ANS-General - fever (subjective) with chills and sweats, denies
fatigue, weakness, weight loss, or malaise
- Skin - denies rashes, lesions, discolorations
- HEENT - positive for generalized headache, sore throat, pain with swallowing and
rhinorrhea. Denies difficulty swallowing saliva, earache, sinus congestion, sinus pain,
visual or auditory aura
- Neck - denies lump, pain, stiffness, or decreased range of motion
- Cardiac - denies chest pain, pressure, tightness, palpitations
- Pulmonary - denies cough, wheeze, hemoptysis
- GI - denies nausea, vomiting, abdominal pain
- GU - denies missed menses, urinary frequency, urgency or hematuria
- MS - denies cramping, pain,
- Neuro - denies unilateral weakness, numbness, tingling
Review of Systems - ANS-• Should elaborate on the chief complaint and HPI • Don't ask
questions that the patient may not know
Review of Systems
Do you have a problem with your prostate? Do have anemia, heart failure, cancer? Do
you frequently urinate during the night? Have you noticed a change in the stream of
your urine? Do you avoid drinking fluids during work? Do you feel tired often? Are you
short of breath? Have you had any weight loss recently?
Objective - ANS-In this section you document what you observe during the examination
and visit.
Physical Examination - ANS-- Vital signs - Physical examination findings - the use of
"normal", "within normal limits", "unremarkable" and other phrases are NOT acceptable.
- Diagnostic results - Measurements including height, weight, screening tools, etc. -
Mental Status
-Weight 50 Kg previously documented height 5'3" -Vital signs - BP 118/76, HR 104, RR
16, T 38.2C, pulse Ox 99% RA -Diagnostic results •Rapid strep test positive
,-Physical examination findings - ANS-• General -Well nourished and hydrated 28 yo
female. Awake, alert and orient; appropriately dressed for season. Pleasant and
cooperative.
*Skin - hot, dry and pink. No rashes or lesions including petechiae noted
• HEENT - normocephalic, symmetric face features. No tenderness in scalp, face,
ethmoid/maxillary/frontal sinuses. Negative transillumination. External ears without
deviations, ear canal clear bilaterally, tympanic membranes pearly grey with cone of
light, bony landmarks visualized bilaterally. Nasal mucosa pink and moist turbinates with
no edema or erythema. Oral mucosa pink and moist, dentition without obvious caries;
no lesions oral cavity. Pharynx with moderate erythema tonsillar pillars ¼ bilaterally. No
exudate. Uvula midline gag reflex present.
• Neck - supple. Anterior cervical lymphadenopathy with mobile, tender nodes bilaterally
all less than 1 cm diameter. No JVD
- Cardiac - S1 S2 with no murmurs, gallops, or clicks. PMI 5th ICS mid-clavicular line
- Pulmonary - lungs clear to auscultation bilaterally in all fields. Negative tactile fremitus,
egophony, bronchophony, and whispered pectoriloquy
- GI - no masses or pulsations. Bowel sounds normoactive all 4 quadrants. No
organomegaly no bruits.
-GU- denies missed menses, urinary frequency, urgency or
hematuria
- MS - Strength 4/5 bilateral upper and lower extremities. Gait steady
- Neuro - awake, alert, and oriented to name, place, date, and surroundings. No nuchal
rigidity, Kernigs or Brudzinski signs
Assessment - ANS-This section is where the diagnosis and differential diagnosis are
listed for the date the note is written.
Sample
Diagnosis: - Strep Pharyngitis
• Differential Diagnosis:
- Viral pharyngitis
- Rheumatic fever
- Scarlet fever
Plan - ANS-This is where the treatment plan goes.
- Medications
- Diagnostic tests (i.e. laboratory, radiologic, hearing, etc.)
- Education
- Counseling
, - Referrals
- Procedures performed and the outcomes/result(s)
- Return to office date(s)/Follow up
Sample
- Amoxicillin 875mg BID for 10 days
- Rapid Strep test done in office
- Verbal instructions given on warm salt water gargles and spit 3-4 times a day; rest;
increased fluids; rest; no work 2 days note given to patient
- Patient instructed to return to the office in 2 days if no improvement. To report to the
emergency department with difficulty swallowing, breathing, rash develops, or
symptoms worse verbalized understanding.
How to Interview a Patient - ANS-Stay calm!! • Prepare before you go into the room -
Read the chart, familiarize yourself with the patient • Set an agenda - Time, needs,
issues • Look and be professional - If you look the part you have already conquered the
first hurdle
Set the Stage - ANS-• Welcome the patient using their name • Introduce yourself and
your role • Remove communication barriers - Family or professional translator • Ensure
patient privacy and comfort • Set the agenda for the visit - What are you going to do
Why is the Patient Here?
• - ANS-• Begin with open-ended questions - Requires patients to actually describe their
complaints - Obtain accurate, patient-specific information • Avoid closed-ended
questions - Similar to a long health history survey - Actually takes longer than
open-ended questions
• Be attentive while the patient is speaking - Of yourself • Silence, non-verbal
encouragement , body language -The Patient • Look for non-verbal signs and cues
• Ask question(s) and then ask again, using the patients own words • What is the
patient's personal story • Ask emotion-seeking questions
Comprehensive or Focused - ANS-Comprehensive • New patients • Identifies and rules
out physical causes related to patient concerns • Baseline • Health promotion
Focused • Established patients • Focused concerns • Symptoms of specific system(s)
Comprehensive History - ANS-• The comprehensive history is to be performed on all
non-emergent, new patients who will be receiving ongoing primary care from a
particular provider or group. • It is also expected within the hospital setting.
