NU552 Journal Templates

NU552 Journal Templates

Unit 2/Module 1 Journal Template. Some of the history is completed. Be sure all sections are complete. Each section of the ROS should be completed. The video is of the ROS interview. This is your associated documentation. Copy and paste your completed template into the Unit 2 text box along with your Kaltura video.

Unit 2/Module 1 Journal NU552

Date Student Name

Complete patient information below.

Date:

MRN:

Age:

Sex:

SUBJECTIVE

CC: well visit

HPI:

Medications: HCTZ 50mg QD. Synthroid brand. 0.75mg QD

Allergies: NKDA

Past Medical History:

HTN, Hypothyroidism.

Cholecystectomy 2019

Family History:

HTN- Father Mother both living

Depression- Sister

DM2- Grandfather-deceased. Brother.

Social History:

Retail Sales

Married

2 children/teens.

Non-smoker

Drinks 1-3 wine glass per week

No illicit drug use

ROS

General

Peripheral Vascular

Skin

Urinary

HEENT

Genitalia/Reproductive

Neck

Musculoskeletal

Breasts

Neurological

Respiratory

Hematologic

Cardiovascular

Endocrine

Comment on considerations of diversity, inclusion, gender, culture, ethnicity, and ethical decision making in the patient interview process. Word count 75-100.

Unit 4/Module 2 Journal Template. Your documentation should align with the objective examination video. Copy and paste your completed template into the Unit 4 text box along with your Kaltura video.

Unit 4/Module 2 Journal NU552

Date Student Name

Complete patient information below.

OBJECTIVE

GENERAL APPEARANCE

HEENT

CARDIOVASCULAR

LUNGS

SKIN

How might diagnostic reasoning and clinical judgment be used to move toward a diagnosis in one of these systems? Include 2-3 evidence based resources, at least one of which is a clinical guideline for a condition that may be a differential. Word count 75-100

Unit 6/Module 3 Journal Template. Your documentation should align with the objective examination video. Copy and paste your completed template into the Unit 6 text box along with your Kaltura video.

Unit 6/Module 3 Journal NU552

Date Student Name:

Complete patient information below.

OBJECTIVE

Breast (provide description do not do the exam in video)

Abdomen

Genitourinary (provide description do not do the exam in video)

Neurological

Psychiatric

How might diagnostic reasoning and clinical judgment be used to move toward a diagnosis in one of these systems? Include 2-3 evidence based resources, at least one of which is a clinical guideline for a condition that may be a differential. Word count 75-100

Unit 8/Module 4 Journal. Your documentation should align with the objective examination video for this specialty assessment. Copy and paste your completed template into the Unit 8 Text box along with your Kaltura video.

Unit 8/Module 4 Journal NU552

Date Student Name:

Complete patient information below.

Part I

Complete the physical assessment documentation per the sports physical requirements. Part I is not performed in the video submission but for your learning practice on sports physical documentation.

Place N in the Normal Column. Place AB in the Abnormal column with a comment if you choose. There does not need to be abnormal findings. If so you must comment.

You must add comments in the heart and genitalia sections (as if for a male).

This is for your learning.

The patient History is completed by the parent first, then an ROS; which are not a part of this journal exercise.

SYSTEM

Patient Name Sex M

HT 5/10 WT 190

T- 98 P-70 R-15 B/P110/7

N

AB

COMMENTS

HEAD

Hair, scalp, masses, injuries

EYES

Proptosis, conjunctivae, sclera, EOMI,

pupillary size, reaction to light,

peripheral vision,

EARS

Gross hearing/ TMs/ Discharge

NOSE

Septum, mucosa, sinuses

THROAT/MOUTH

Teeth condition, tongue, tonsils, lesions

NECK

Thyroid, vessels, range of motion, adenopathy, masses, voice abnormalities

THORAX/LUNGS

Shape, expansion, deformities, rhonchi, wheezes, rales

HEART

PMI, sounds, thrills, murmurs, gallops,

LYMPHATICS

Cervical, axillary

ABDOMEN

Organ enlargement (liver, spleen, etc.), masses, tenderness, hernias, scars

GENITALIA

Scrotum, testicles, lesions, discharge, hernias

(female deferred)

UPPER EXTREMITIES

Range of motion, joint stability, muscle strength, limitations, effusion, ecchymoses, atrophy, deformities, edema, clubbing, pulses, veins, injuries

LOWER EXTREMITIES

Range of motion, joint stability, muscle strength, limitations, effusion, ecchymoses, atrophy, deformities, edema, clubbing, pulses, veins, injuries

BACK

Flexion, extension, scoliosis, kyphosis, excessive lordosis, injuries

NEUROLOGICAL

Cranial nerves, reflexes, motor, gait, balance, sensory

SKIN

Texture, striae, rash, acne

MENTAL STATUS

Affect, hostility, agitation

OBJECTIVE

Part II Complete the MS and Peripheral Vascular exam documentation as in a physical exam for this component of a sport physical exam with detail and specifics as would be appropriate for this specialty exam. This should be more than Normal or Abnormal for this journal exercise. Sign the form by typing your name or using the draw feature.

Musculoskeletal

Peripheral Vascular

Approved Y/ N Provider Signature ________________________________

How might diagnostic reasoning and clinical judgment be used to move toward a diagnosis during this assessment? Include 2-3 evidence based resources about sports physical exam considerations; at least one of which is a clinical guideline for a condition that may be a differential if any abnormalities were found. Use an example. Word count 75-100

Unit 9/Module 5 Journal.

Complete the full subjective and objective assessment below. Your subjective interview responses should lean toward some topics related to an older adult and the typical ROS. Your video is the objective portion only. It should align with the objective documentation. The breast and GU exam are deferred. Copy and paste your completed template into the Unit 9 Text box along with your Kaltura video.

Unit 9/Module 5 Journal NU552

Your Name

Date

Patient Name:

Pt. Encounter Number:

Date:

Age:

Sex:

SUBJECTIVE

CC:

HPI:

Medications:

Allergies: NKDA

Past Medical History:

Family History

Social History

ROS

General

Peripheral Vascular

Skin

Urinary

HEENT

Genitalia/Reproductive

Neck

Musculoskeletal

Breasts

Neurological

Respiratory

Hematologic

Cardiovascular

Endocrine

OBJECTIVE

Weight 180

Ht 5’6’’

BMI 29

SPO2 96%

B/P 140/70

P 88

R 22

Temp 98

General Appearance

Skin

HEENT

Cardiovascular

Respiratory

Abdomen

Breast DEFERRED

Genitourinary DEFERRED

Musculoskeletal/Spine

Neurological

Psychiatric

How might diagnostic reasoning and clinical judgment be used to move toward a diagnosis in one of these systems? In your response include physical changes in older adults. Include 2-3 evidence based resources, at least one of which is a clinical guideline for a condition that may be a differential. Word count 75-100