Copyright © 2015 by Mosby, an imprint of Elsevier Inc.x-3

Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
x-3
Student Checklist
Ball: Seidel’s Guide to Physical Examination, 8th Edition
Chapter 05: Mental Status
Student Checklist
Adult Examination Checklist
Mark data, when appropriate, to indicate the following:
If normal, * if abnormal, O if absent.
Subjective Data
__Alertness
__Emotional status
__Orientation
__Time
__Place
__Person
__Analogies (similarities)
__Abstract reasoning (fable, proverb)
__Arithmetic calculations
__Writing ability
__Motor skills
__Memory
__Immediate
__Recent
__Remote

__Attention span (short commands)
__Judgment/decision making (hypothetical situation)
__Voice
__Quality
__Pace
__Loudness
__Articulation
__Comprehension
__Coherence (perceptions clearly conveyed)
__Mood and feelings
__Thought processes (logical)
__Perceptual distortions (hallucinations)
Objective Data
Observation
__Alertness
__Grooming
__Body language
__Emotional status
__Attention span
__Coherence
__Voice
__Quality
__Pace
__Loudness
__Articulation
__Comprehension
__Mood and feelings
__Thought processes
__Perceptual distortions
Testing
__Orientation
__Time
__Place
__Person
__Analogies
__Abstract reasoning

__Arithmetic calculations
__Writing ability
__Motor skills
__Memory
__Immediate
__Recent
__Remote
__Attention span
5-2
Student Checklist
Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
Detail those data marked as abnormal:
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying why the
patient is here - in the patient’s own words - for instance
"headache", NOT "bad headache for 3 days”.
HPI: This is the symptom analysis section of your note.
Thorough documentation in this section is essential for patient
care, coding, and billing analysis. Paint a picture of what is
wrong with the patient. Use LOCATES Mnemonic to complete
your HPI. You need to start EVERY HPI with age, race, and
gender (e.g., 34-year-old AA male). You must include the seven
attributes of each principal symptom in paragraph form not a
list. If the CC was “headache”, the LOCATES for the HPI might
look like the following example:
Location: head

Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia,
phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes
it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time
used and reason for use; also include OTC or homeopathic
products.
Allergies: include medication, food, and environmental allergies
separately (a description of what the allergy is ie angioedema,
anaphylaxis, etc. This will help determine a true reaction vs
intolerance).
PMHx: include immunization status (note date of last tetanus
for all adults), past major illnesses and surgeries. Depending on
the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status,
tobacco & alcohol use (previous and current use), any other
pertinent data. Always add some health promo question here -
such as whether they use seat belts all the time or whether they
have working smoke detectors in the house, living environment,
text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition,
contagious or chronic illnesses. Reason for death of any
deceased first degree relatives should be included. Include
parents, grandparents, siblings, and children. Include
grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule
out a differential diagnosis You should list each system as
follows: General:Head: EENT: etc. You should list these in
bullet format and document the systems in order from head to
toe.
Example of Complete ROS:

GENERAL: Denies weight loss, fever, chills, weakness or
fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision
or yellow sclerae. Ears, Nose, Throat: Denies hearing loss,
sneezing, congestion, runny nose or sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or
chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting or
diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last
menstrual period, MM/DD/YYYY.
NEUROLOGICAL: Denies headache, dizziness, syncope,
paralysis, ataxia, numbness or tingling in the extremities. No
change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain
or stiffness.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No history of
splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denies reports of sweating, cold or heat
intolerance. No polyuria or polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema or
rhinitis.
O.
Physical exam: From head-to-toe, include what you see, hear,
and feel when doing your physical exam. You only need to
examine the systems that are pertinent to the CC, HPI, and
History. Do not use “WNL” or “normal.” You must describe
what you see. Always document in head to toe format i.e.
General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics
that are needed to develop the differential diagnoses (support
with evidenced and guidelines)

A.
Differential Diagnoses (list a minimum of 3 differential
diagnoses).Your primary or presumptive diagnosis should be at
the top of the list. For each diagnosis, provide supportive
documentation with evidence based guidelines.
P.
This section is not required for the assignments in this course
(NURS 6512) but will be required for future courses.
References
You are required to include at least 8 evidence based peer -
reviewed journal articles or evidenced based guidelines which
relates to this case to support your diagnostics and differentials
diagnoses. Be sure to use correct APA 7th edition formatting.
© 2021 Walden University, LLC
Page 1 of 3
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying why the
patient is here - in the patient’s own words - for instance
"headache", NOT "bad headache for 3 days”.
HPI: This is the symptom analysis section of your note.
Thorough documentation in this section is essential for patient
care, coding, and billing analysis. Paint a picture of what is
wrong with the patient. Use LOCATES Mnemonic to complete
your HPI. You need to start EVERY HPI with age, race, and

gender (e.g., 34-year-old AA male). You must include the seven
attributes of each principal symptom in paragraph form not a
list. If the CC was “headache”, the LOCATES for the HPI might
look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia,
phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes
it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time
used and reason for use; also include OTC or homeopathic
products.
Allergies: include medication, food, and environmental allergies
separately (a description of what the allergy is ie angioedema,
anaphylaxis, etc. This will help determine a true reaction vs
intolerance).
PMHx: include immunization status (note date of last tetanus
for all adults), past major illnesses and surgeries. Depending on
the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status,
tobacco & alcohol use (previous and current use), any other
pertinent data. Always add some health promo question here -
such as whether they use seat belts all the time or whether they
have working smoke detectors in the house, living environment,
text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition,
contagious or chronic illnesses. Reason for death of any
deceased first degree relatives should be included. Include
parents, grandparents, siblings, and children. Include
grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule

out a differential diagnosis You should list each system as
follows: General:Head: EENT: etc. You should list these in
bullet format and document the systems in order from head to
toe.
Example of Complete ROS:
GENERAL: Denies weight loss, fever, chills, weakness or
fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision
or yellow sclerae. Ears, Nose, Throat: Denies hearing loss,
sneezing, congestion, runny nose or sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or
chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting or
diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last
menstrual period, MM/DD/YYYY.
NEUROLOGICAL: Denies headache, dizziness, syncope,
paralysis, ataxia, numbness or tingling in the extremities. No
change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain
or stiffness.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No history of
splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denies reports of sweating, cold or heat
intolerance. No polyuria or polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema or
rhinitis.
O.
Physical exam: From head-to-toe, include what you see, hear,
and feel when doing your physical exam. You only need to
examine the systems that are pertinent to the CC, HPI, and
History. Do not use “WNL” or “normal.” You must describe

what you see. Always document in head to toe format i.e.
General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics
that are needed to develop the differential diagnoses (support
with evidenced and guidelines)
A.
Differential Diagnoses (list a minimum of 5 differential
diagnoses).Your primary or presumptive diagnosis should be at
the top of the list. For each diagnosis, provide supportive
documentation with evidence based guidelines.
P.
This section is not required for the assignments in this course
(NURS 6512) but will be required for future courses.
References
You are required to include at least eight evidence based peer -
reviewed journal articles or evidenced based guidelines which
relates to this case to support your diagnostics and differentials
diagnoses. Be sure to use correct APA 7th edition formatting.
Page 1 of 3
Week 9
Shadow Health Comprehensive SOAP Note Template
Patient Initials: _______ Age: _______
Gender: _______
SUBJECTIVE DATA:

Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Health Maintenance:
Immunization History:
Significant Family History:
Review of Systems:
General:
HEENT:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Neurological:
Psychiatric:
Skin/hair/nails:

OBJECTIVE DATA:
Physical Exam:
Vital signs:
General:
HEENT:
Neck:
Chest/Lungs:.
Heart/Peripheral Vascular:
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:
Diagnostic results:
ASSESSMENT:
PLAN: This section is not required for the assignments in this
course (NURS 6512), but will be required for future courses.
Page 2 of 3
Neurological Symptoms
Week 9 Assignment
HH is a 68 yo M who has been admitted to the medical ward
with community-acquired pneumonia for the past 3 days.
His PMH is significant for COPD, HTN, hyperlipidemia, and
diabetes.
He remains on empiric antibiotics, which include ceftriaxone 1
g IV qday (day 3) and azithromycin 500 mg IV qday (day 3).

Since admission, his clinical status has improved, with
decreased oxygen requirements. He is not tolerating a diet at
this time with complaints of nausea and vomiting.
Ht: 5’8” Wt: 89 kg Complex Case
Allergies: Penicillin (rash)
With regard to the case study you were assigned:
· Review this week's Learning Resources, and consider the
insights they provide about the case study.
· Consider what history would be necessary to collect from the
patient in the case study you were assigned.
· Consider what physical exams and diagnostic tests would be
appropriate to gather more information about the patient's
condition. How would the results be used to make a diagnosis?
· Identify at least five possible conditions that may be
considered in a differential diagnosis for the patient.
The Case Study Assignment
Use the Episodic/Focused SOAP Template and create an
episodic/focused note about the patient in the case study to
which you were assigned using the episodic/focused note
template provided in the Week 5 resources. Provide evidence
from the literature to support diagnostic tests that would be
appropriate for each case. List five different possible conditions
for the patient's differential diagnosis, and justify why you
selected each.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2019). Seidel's guide to physical examination:
An interprofessional approach (9th ed.). St. Louis, MO: Elsevier
Mosby.
· Chapter 7, “Mental Status”
This chapter revolves around the mental status evaluation of an

individual’s overall cognitive state. The chapter includes a list
of mental abnormalities and their symptoms.
· ·Chapter 23, “Neurologic System”
The authors of this chapter explore the anatomy and physiology
of the neurologic system. The authors also describe neurologi cal
examinations and potential findings.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced
health assessment and clinical diagnosis in primary care (6th
ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical
Diagnosis in Primary Care, 6th Edition by Dains, J.E.,
Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby.
Reprinted by permission of Mosby via the Copyright Clearance
Center.
Chapter 4, “Affective Changes”
This chapter outlines how to identify the potential cause of
affective changes in a patient. The authors provide a suggested
approach to the evaluation of this type of change, and they
include specific tools that can be used as part of the diagnosis.
Chapter 9, “Confusion in Older Adults”
This chapter focuses on causes of confusion in older adults,
with an emphasis on dementia. The authors include suggested
questions for taking a focused history as well as what to look
for in a physical examination.
Chapter 13, “Dizziness”
Dizziness can be a symptom of many underlying conditions.
This chapter outlines the questions to ask a patient in taking a
focused history and different tests to use in a physical
examination.
Chapter 19, “Headache”

The focus of this chapter is the identification of the causes of
headaches. The first step is to ensure that the headache is not a
life-threatening condition. The authors give suggestions for
taking a thorough history and performing a physical exam.
Chapter 31, “Sleep Problems”
In this chapter, the authors highlight the main causes of sleep
problems. They also provide possible questions to use in taking
the patient’s history, things to look for when performing a
physical exam, and possible laboratory and diagnostic studies
that might be useful in making the diagnosis.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd
ed.). Philadelphia, PA: F. A. Davis.
· Chapter 2, "The Comprehensive History and Physical Exam"
("Cranial Nerves and Their Function" and "Grading Reflexes")
(Previously read in Weeks 1, 2, 3, and 5)
Note: Download the Physical Examination Objective Data
Checklist to use as you complete the Comprehensive (Head-to-
Toe) Physical Assessment assignment.
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon,
B. S., & Stewart, R. W. (2011). Physical examination objective
data checklist. In Mosby’s guide to physical examination (7th
ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Mosby’s Guide to Physical Examination, 7th
Edition by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A.,
Solomon, B. S., & Stewart, R. W. Copyright 2011 by Elsevier.
Reprinted by permission of Elsevier via the Copyright
Clearance Center.
Note: Download and review the Student Checklists and Key
Points to use during your practice neurological examination.
Stewart, R. W. (2019). Neurologic system: Student checklist. In

Seidel's guide to physical examination: An interprofessional
approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th
Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B.
S., & Stewart, R. W. Copyright 2019 by Elsevier Health
Sciences. Reprinted by permission of Elsevier Health Sciences
via the Copyright Clearance Center.
Stewart, R. W. (2019). Neurologic system: Key points. In
Stewart, R. W. (2019). Mental status: Student checklist. In
Bearden , S. T., & Nay, L. B. (2011). Utility of EEG in
differential diagnosis of adults with unexplained acute
alteration of mental status. American Journal of
Electroneurodiagnostic Technology, 51(2), 92–104.
This article reviews the use of electrocenographs (EEG) to
assist in differential diagnoses. The authors provide differential

diagnostic scenarios in which the EEG was useful.
Athilingam, P ., Visovsky, C., & Elliott, A. F. (2015). Cognitive
screening in persons with chronic diseases in primary care:
Challenges and recommendations for practice. American Journal
of Alzheimer’s Disease & Other Dementias, 30(6), 547–558.
doi:10.1177/1533317515577127
Sinclair , A. J., Gadsby, R., Hillson, R., Forbes, A., & Bayer, A.
J. (2013). Brief report: Use of the Mini-Cog as a screening tool
for cognitive impairment in diabetes in primary care. Diabetes
Research and Clinical Practice, 100(1), e23–e25.
doi:10.1016/j.diabres.2013.01.001
Roalf, D. R., Moberg, P. J., Xei, S. X., Wolk, D. A., Moelter, S.
T., & Arnold, S. E. (2013). Comparative accuracies of two
common screening instruments for classification of Alzheimer’s
disease, mild cognitive impairment, and healthy aging.
Alzheimer’s & Dementia, 9(5), 529–537.
doi:10.1016/j.jalz.2012.10.001. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4036230/

Copyright © 2015 by Mosby, an imprint of Elsevier Inc.x-3

Recommandé

Recommandé

Contenu connexe

Similaire à Copyright © 2015 by Mosby, an imprint of Elsevier Inc.x-3

Similaire à Copyright © 2015 by Mosby, an imprint of Elsevier Inc.x-3 (20)

Plus de AlleneMcclendon878

Plus de AlleneMcclendon878 (20)

Dernier

Dernier (20)

Copyright © 2015 by Mosby, an imprint of Elsevier Inc.x-3