Unit 1 Case Studies

10556NU610 Unit 1 Case Study
A 50-year-old man comes to your office for a routine physical examination. He is a new patient in your
practice. He states his father died at the age of 73 of a heart attack. His mother is alive at the age of 80.
He has hypertension, and he takes chlorthalidone 25 mg PO daily. Takes Tylenol as needed for pain.
Denies seasonal or drug allergies. He has two younger siblings with no known chronic medical
conditions. Last eye and dental exam two years ago. He is married in a monogamous relationship
without children. Has a high school diploma. Works full-time for a local landscaping business. He does
not smoke, use alcohol, or use any recreational drugs. The patient does not exercise. He denies fever,
chills, weight loss, or weight gain. He denies hearing changes, headaches, or dizziness. He reports some
visual changes when reading close-up. He denies shortness of breath, dyspnea on exertion, swelling, or
chest pain. He reports increased urination and thirst. Denies abdominal pain, nausea, vomiting, or
changes in appetite. He reports daily BM. Denies rashes or bug bites. Uses sunscreen daily due to
working outside. Denies anxiety or depression. On examination, his blood pressure is 126/82, and his
pulse is 80 beats/min with a respiratory rate is 18. Height is 67 inches, and weight is 190lbs. Does not
appear in acute distress, responses are appropriate and appears to be a reliable source. Alert, oriented
to person, place, time, and situation. Well-nourished, skin warm, dry, and intact. Normocephalic.
Pupils size 3 mm, equal and reactive to light. Extraocular eye movements are intact in six directions.
Tympanic membranes are gray with an adequate cone of light bilaterally. Mucous membranes are pink
and moist. No palpable masses, thyromegaly, lymphadenopathy, or JVD. Regular heart rate and
rhythm, S1 and S2. No bruits auscultated. Capillary refill less than 3 seconds. Breath sounds clear
bilaterally to auscultation. No use of accessory muscles or purse lip-breathing. Soft, non-tender, non-
distended, normoactive bowel sound. No organomegaly or guarding. Denies numbness or tingling. He
reports he has not had HIV or PSA screenings.

NU610 Unit 1 Assignment – Case Studies Rubric
NU610 Unit 1 Assignment – Case Studies Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeSubjective Data
40 pts
Highly Proficient
Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are well written with few to no omissions or misclassifications of data from the case for all 9 elements.
32 pts
Proficient
Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are well written with few to no omissions or misclassifications of data from the case at least 7 of the 9 elements.
24 pts
Marginally Proficient
Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are well written with few to no omissions or misclassifications of data from the case for at least 5 of the 9 elements.
16 pts
Approaching Proficiency
Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are documented partially correct for at least 3 of the 9 elements.
8 pts
Not Proficient
Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are not documented partially correct for any of the elements.
0 pts
Not Evident
An assignment submission is not located.
40 pts
Instructions
Review the following case study.
Construct a subjective data set for the case study in a Word file from the information provided.
Structure the subjective data set in the format provided in your lecture materials.
Submit the Word file containing your subjective data set into Canvas.
To support your success on the assignment the SOAP Note Assignment Instructions are attached here for your review of how to structure a subjective data set.