🔍 Case Study Focus
Unit 1 of NU610 typically introduces students to the foundational principles of advanced health assessment. The case study often involves evaluating a patient’s history, performing a comprehensive physical exam, and identifying differential diagnoses based on clinical findings.
🧩 Key Concepts
1. Comprehensive Health History
Includes chief complaint (CC), history of present illness (HPI), past medical history (PMH), family history (FH), social history (SH), and review of systems (ROS).
Important to document subjective data accurately.
2. Physical Examination Techniques
Inspection, palpation, percussion, and auscultation.
Tailored to the patient’s presenting symptoms.
Objective data should be clearly recorded.
3. Clinical Reasoning
Use findings to develop differential diagnoses.
Consider age, gender, risk factors, and symptom patterns.
Prioritize diagnoses based on likelihood and severity.
4. SOAP Note Format
Subjective: Patient-reported symptoms.
Objective: Measurable findings from the exam.
Assessment: Differential diagnoses.
Plan: Diagnostic tests, referrals, treatment, and follow-up.
5. Cultural Competence
Respect patient beliefs, language, and health practices.
Use interpreters when needed.
Avoid assumptions based on ethnicity or background.
6. Diagnostic Reasoning
Integrate subjective and objective data.
Use evidence-based guidelines to support decisions.
Consider red flags and urgent conditions.
7. Communication Skills
Use open-ended questions.
Practice active listening.
Ensure patient understanding and consent.
📝 Practice Quiz (15 Questions)
1. What does the acronym HPI stand for in a health history? a) Health Practice Index b) History of Present Illness c) Hospital Patient Information d) Health Problem Identification Answer: b
2. Which of the following is considered subjective data? a) Blood pressure reading b) Lung sounds c) Patient’s report of chest pain d) Laboratory results Answer: c
3. What is the first step in a physical examination? a) Palpation b) Percussion c) Inspection d) Auscultation Answer: c
4. Which section of the SOAP note includes the nurse practitioner’s diagnosis? a) Subjective b) Objective c) Assessment d) Plan Answer: c
5. What is the purpose of the review of systems (ROS)? a) To document lab results b) To summarize the treatment plan c) To identify symptoms across body systems d) To record vital signs Answer: c
6. Which of the following is an example of objective data? a) Patient says they feel dizzy b) Patient reports nausea c) Temperature of 38.5°C d) Patient complains of fatigue Answer: c
7. What does the “P” in SOAP note stand for? a) Palpation b) Plan c) Patient d) Procedure Answer: b
8. Which technique is used to assess for fluid in the lungs? a) Palpation b) Percussion c) Auscultation d) Inspection Answer: c
9. What is a differential diagnosis? a) A confirmed diagnosis b) A list of possible conditions based on symptoms c) A treatment plan d) A lab test result Answer: b
10. Why is cultural competence important in health assessment? a) It reduces documentation time b) It improves billing accuracy c) It enhances patient trust and care outcomes d) It eliminates the need for interpreters Answer: c
11. Which of the following is a red flag symptom? a) Mild headache b) Sudden vision loss c) Fatigue after exercise d) Occasional sneezing Answer: b
12. What is the best way to begin a patient interview? a) With yes/no questions b) With open-ended questions c) By asking about insurance d) By listing diagnoses Answer: b
13. What does auscultation involve? a) Listening with a stethoscope b) Feeling for abnormalities c) Tapping to detect density d) Observing skin color Answer: a
14. Which part of the health history includes lifestyle habits? a) Family history b) Social history c) Past medical history d) Review of systems Answer: b
15. What is the goal of diagnostic reasoning? a) To confirm a single diagnosis b) To eliminate all possible conditions c) To integrate data and guide clinical decisions d) To avoid ordering tests Answer: c