Simulation Case Study #2 Comprehensive Health History and a Focused Physical Examination

Instructions

To prepare:

Review Learning Resources in Weeks 1–4.
Download and review the “Comprehensive Health History Reference SheetDownload Comprehensive Health History Reference Sheet” and the “Physical Exam Reference SheetDownload Physical Exam Reference Sheet.”
Access Simulation Case Study #2: Painful RashLinks to an external site..
Review current evidence-based guidelines related to the patient complaint.
Download the Assignment TemplateDownload Download the Assignment Template.
The Assignment

Based on the case, complete document a comprehensive health history (subjective data only) and a focused physical examination (objective data only).

Do NOT provide:

A diagnosis
A differential diagnosis list
A treatment plan
Prescriptions
Patient education
This assignment evaluates assessment and documentation skills only.

Expand the health history and focused physical examination results as appropriate by identifying and documenting expected findings. You may include your own version of history sections as you see fit. In other words, you can formulate your own health history and objective data of the patient as long as it is properly documented.

Part I: Comprehensive Health History (Subjective Data Only)
Reminder: The health history includes only information provided by the patient. It should not include physical exam findings.
You must:
Expand the HPI using OLDCARTS
Write the HPI as a cohesive paragraph (not bullet points)
Include complete PMH, PSH, medications, allergies, preventive health, social history, and SDOH
Complete a comprehensive or focused ROS (subjective only)

Part II: Focused Physical Examination (Objective Data Only)
Reminder: The physical exam includes only what the clinician observes, palpates, percusses, or auscultates.
You must:
Perform and document a focused examination appropriate to the chief complaint,
Determine and document what objective findings you would expect to assess and record based on your clinical reasoning.
Documentation Expectations
You must:
Clearly separate subjective and objective data
Avoid including patient-reported symptoms in the physical exam section
Avoid including exam findings in the history section
Use professional medical terminology
Demonstrate logical organization
Align examination scope with the chief complaint
Evidence-Based Practice Requirement
Your documentation must incorporate a minimum of three, evidence-based scholarly references published within the last five years (≤ 5 years old). Cite all sources in APA format.
References must support:
Clinical assessment of integumentary complaints
Focused skin examination principles
Any portion of the reflection section
Acceptable Sources:
Peer-reviewed journal articles
CDC clinical guidance
IDSA guidelines
Advanced practice nursing scholarly texts
WHO clinical documents
Unacceptable Sources:
Patient education websites (e.g., Mayo Clinic, Cleveland Clinic, WebMD, Healthline)
Wikipedia
Blogs or commercial health sites
All references must be cited in APA format.
Part III: Reflection (1–2 pages)
After completing your comprehensive health history and focused physical examination, submit a reflection addressing the reflection prompts in the assignment template. This reflection is designed to help you strengthen your ability to clearly separate subjective and objective findings while performing an integumentary assessment.