Data Gathering

Data Gathering 

A. GUIDELINES FOR INDIVIDUALLY- ASSIGNED OSCE CASE STUDIES:

 

  

 

1. Student will develop and complete My Checklist and Patient Notes of assigned case  

    scenarios per week using the templates for My Checklist and Patient Note which will be  

    submitted in the Blackboard under Assignment Tab with heading OSCE case studies. 

2. The completed My checklist and Patient Notes for all weekly-assigned case scenarios will  

    be submitted on or before the given deadline.  

3. All assigned case scenarios can be retrieved from Mastering the USMLE Step 2 CS  

  

  Clinical Examination; Reteguiz (2013) 3rd edition, ISBN-13: 978-0071443340, the  

   course supplemental reference material. 

4. See rubric for grading of assignments and late assignments will follow late assignment submission policy 

 

Assigned Case Scenarios and Deadline of Submission: 

1. 46-year-old woman complaining of fatigue and weight gain   

2. 65-year-old woman complaining of hearing loss   

3. 20-year-old woman complaining of a cough for 4 days   

4. 25-year-old man complaining of a sore throat   

5. 68-year-old man requesting pain medications  

6. 50-year-old woman requesting a blood pressure check   

7. 55-year-old man complaining of chronic abdominal pain   

8. 48-year-old man with chest pain   

9. 25-year-old woman with leg pain  

10. 35-year-old man with a chronic cough 

USE EACH OF THE ABOVE CASE SCENARIOS AS YOUR PATIENTS AND USE THE BELOW TABLE. FOR EACH PATIENT. WRITE YOUR NARRATIVE NOTES AFTER ENCOUNTERED WITH YOUR PATIENT 

 

Data Gathering (DG)/MY CHECKLIST: (10 points X 2.5 %) = 2.5 

 Chief Complaint: 

History of Present Illness. The Examinee: (4 points) 

1.___________________________________________________________________________2.___________________________________________________________________________3.___________________________________________________________________________ 

4.___________________________________________________________________________5.___________________________________________________________________________ 

Past Medical History: 

6.___________________________________________________________________________ 

7. __________________________________________________________________________ 

Family History: 

8. __________________________________________________________________________ 

9. __________________________________________________________________________ 

Social History: 

10. ________________________________________________________________________ 

11. ________________________________________________________________________ 

Review of Systems: 

12. _______________________________________________________________________ 

13. _______________________________________________________________________ 

  
  

Physical Examination. The Examinee: (4 points) 

14.__________________________________________________________________________ 

15.__________________________________________________________________________ 

16.__________________________________________________________________________ 

17.__________________________________________________________________________ 

18.__________________________________________________________________________ 

  

Communication Skills. The Examinee: (2 points) 

19.__________________________________________________________________________ 

20._________________________________________________________________________ 

21.__________________________________________________________________________ 

  
  

 Please fellow the below RUBRICS for grading 

Required elements/grading rubric of the Patient Note  

  

1.Subjective (2 points) 

State the patient’s chief complaint, reason for visit and/or the problem for which the patient sought consultation. 

a. History of Present Illness: All symptoms related to the problem are described using the  

    following cue descriptive categories: 

1)         Precipitating/alleviating factors (including prescribed and/or self-remedies  

            and their effect on the problem). 

2)         Associated symptoms 

3)         Quality of all reported symptoms including the effect on the patient’s lifestyle 

4)         Temporal factors (date of onset, frequency, duration, sequence of events) 

5)         Location (localized or generalized? does it radiate?) 

6)         Sequelae (complications, impact on patient and/or significant others 

7)         Severity of the symptoms 

  

b.         Past Medical History including immunizations, allergies, accidents, illnesses,  

            operations, hospitalizations. 

c.         Family History includes family members’ health history. 

d.         Social history to include habits, residence, financial situation, outside assistance,  

           family inter-relationships. 

e.         Review of Systems relevant to the chief complaint/presenting problem is included.  

            Include pertinent positives and negatives. 

2.  Objective (3points) 

a.         Using problem-focused examination re: inspection, palpation, percussion, and   

             auscultation, the examiner evaluates pertinent systems associated with the   subjective complaint including applicable systems which may be causing the          problem, or which will manifest or may potentially manifest complications and records            positive and pertinent negative findings 

b.         Performs appropriate diagnostic studies if equipment is available 

c.         Records results of pertinent, previously obtained diagnostic studies. 

d.         Use Handout Guidelines to Physical Examination. 

3.  Assessment (3 points) 

a.         Diagnosis/es with pathophysiology is (are) derived from the subjective and objective   

             data 

b.         Differential diagnoses with pathophysiology are prioritized – (minimum of 3) 

c.         Diagnosis/es come(s) from the medical domain 

d.         Assessment includes health risks/needs assessment 

  

4.  Plan (2 points) 

a.         Appropriate diagnostic studies with rationale 

b.         Therapeutic treatment plan with rationale 

c.         Was this patient appropriate for a nurse practitioner as a provider? Is consultation or  

            collaboration with another health care provider required? 

d.         Health promotion/disease prevention carried out or planned: education, discussion,  

            handouts given, evidence of patient’s understanding. 

e.         What community resources are available in the provision of care for this client? 

f.          Referrals initiated (including to whom the patient is referred to and the purpose)  

g.         Target dates for re-evaluating the results of the plan and follow up. 

WRITE YOUR NURSING NARRATIVE NOTES ON YOUR SUBJECTIVEO DATA GETHERED FROM THE PATIENT, PATIENT RESPONSE TO YOUR QUESTIONS, WHAT YOU OBSERVED, DIAGNASTIC THAT YOU WILL ORDERED AS NP,  YOUR PLAN AND AND EXPRESS YOUR EMPATHY.