Simulation Case Studies -Burning In Chest After Eating – NURS-6512 week 7 Angela Brooks
Burning in Chest After Eating Presentation
Angela Brooks
Age:
52
Sex:
Female
Race/Ethnicity:
African American
Marital Status:
Divorced
Occupation:
Real Estate Agent
Insurance:
Private
Living Situation:
Lives alone
Chief Complaint (CC):
Burning in Chest After Eating
Patient Statement
For about the past three or four months, I’ve been getting this burning feeling in the middle of my chest after I eat. It usually starts about 30 minutes to an hour after meals, especially if I eat something spicy or fried. Sometimes it feels like the food is coming back up into my throat, and I get a sour taste in my mouth.
It’s not really a sharp pain — more like a burning pressure. I’d rate it about a 5 out of 10. It’s worse when I lie down at night, and I’ve had to prop myself up on pillows. I’ve also noticed I clear my throat a lot in the mornings.
I haven’t had shortness of breath. No sweating. No pain going into my arm or jaw. I haven’t thrown up, and I haven’t seen any blood. My weight has been stable.
I drink coffee every morning and usually have a glass of wine a few nights a week. I’ve been under some stress lately and probably eat out more than I should. I’ve been taking over-the-counter antacids, and they help, but the symptoms keep coming back.
Week 7
This week you’ll step into the role of the primary care provider as you complete
Simulation Case Study #3.
Your goal is to gather a thorough health history, perform a focused physical examination, and use your clinical reasoning skills to develop appropriate differential diagnoses before identifying the most likely diagnosis. Think like a detective—collect the clues, analyze the evidence, and support every clinical decision with sound reasoning.
🚫
AI Policy: Level 1 Assignment
This is a
Level 1: No AI Permitted
assignment.
AI tools may
not
be used at any point during this assignment. Your history, physical exam findings, diagnostic reasoning, and written work must represent your own clinical thinking.
📚
Before You Begin
Be sure to review the following resources before opening the simulation:
Comprehensive Health History Reference Sheet
Physical Exam Reference Sheet
Assessment Reference Sheet
Week 7 Assignment Template
Also spend some time reviewing current evidence-based guidelines related to your patient’s presenting complaint before beginning the assignment.
🩺
Your Mission
You’ll complete a comprehensive patient assessment that includes:
Part I: Comprehensive Health History (Subjective)
Document:
Identifying data
Chief complaint
OLDCARTS HPI written as a cohesive narrative
Medications
Past medical history
Surgical history
Family history
Preventive screenings
Social history and Social Determinants of Health (SDOH)
Focused Review of Systems (ROS)
💡
Remember:
The ROS is
subjective only.
If the patient didn’t tell you about it, it doesn’t belong here.
Part II: Focused Physical Examination (Objective)
Document expected objective findings that support your assessment.
You may develop your own examination findings as long as they are clinically appropriate and consistent with your patient’s presentation.
Keep subjective and objective information completely separate.
Part III: Assessment & Diagnostic Reasoning
This is where your clinical reasoning shines.
Include:
✅ At least
three differential diagnoses
✅ One
primary diagnosis
For each differential diagnosis discuss:
Pathophysiology
Pertinent positives
Pertinent negatives
Why the diagnosis is ruled in
For your final diagnosis:
Justify your clinical decision
Correlate subjective and objective findings
Explain why the remaining differentials are less likely
Finally, complete the
Final Problem Statement
using the template provided.
📖
Evidence-Based Practice
Support your documentation with
at least three scholarly references published within the last five years.
Be sure your references support your diagnostic reasoning and management of your patient’s presenting complaint.
✔
Acceptable Sources
Peer-reviewed journal articles
Professional clinical practice guidelines
Evidence-based advanced practice nursing texts
CDC or WHO clinical publications (when applicable)
❌
Do Not Use
Mayo Clinic
Cleveland Clinic
WebMD
Healthline
Wikipedia
Blogs or commercial websites
All references must be cited in current APA format.
💭
Part IV: Reflection
Finish your assignment by completing the 1–2 page reflection included in the template. This is your opportunity to think through your clinical reasoning process and reflect on the importance of accurately separating subjective and objective documentation.
⭐
Tips for Success
Think like a provider—not just about what fits, but also what
doesn’t
Support every diagnosis with pertinent positives
and
pertinent negatives.
Keep subjective and objective findings separate throughout your documentation.
Review the grading rubric before submitting your assignment.
Remember that strong documentation tells the patient’s story while demonstrating sound clinical reasoning.
📅
Due Date
Submit your completed assignment by Sunday at 10:59 PM CT.
Have a great week! This case is an excellent opportunity to continue strengthening the diagnostic reasoning skills you’ll use throughout your advanced practice career. As always, please reach out if you have any questions along the way.
NURS 6512
Week 7 Assignment Template
Comprehensive Health History, Physical Examination, and Assessment Template
Part I: Comprehensive Health History (Subjective Data Only)
Subjective Data
Chief Complaint (CC):
History of Present Illness (HPI):
Past Medical History (PMH):
Surgical History (PSH):
Medications:
Allergies:
Preventive Health:
Social History:
Review of Systems (ROS) (Subjective Data Only – Patient-Reported Symptoms):
General:
Skin:
HEENT:
Cardiac:
Respiratory:
Gastrointestinal (GI):
Genitourinary (GU):
Musculoskeletal (MSK):
Neurologic:
Psychiatric:
Endocrine:
Hematologic/Lymphatic/Immune:
Part II: Focused Physical Examination (Objective Data Only)
Physical Examination: Objective Data Only (Do NOT include subjective statements):
General:
Skin:
Head:
Eyes:
Ears:
Nose:
Mouth/Throat:
Neck:
Cardiac:
Lungs:
Abdomen:
Genitourinary (GU):
Musculoskeletal:
Lower Extremities:
Neurologic:
Part III: Assessment and Diagnostic Reasoning
Part III, Section 1: Three Differential Diagnoses
Directions:
Using the template below, for each differential diagnosis, provide pathophysiologic explanation, identify pertinent positives, identify pertinent negatives, explain why it is ruled in or ruled out.
Differential Diagnosis #1:
Condition:
Rationale:
Pertinent positives and negatives:
Differential Diagnosis #2:
Condition:
Rationale:
Pertinent positives and negatives:
Differential Diagnosis #3:
Condition:
Rationale:
Pertinent positives and negatives:
Part III, Section 2: One Primary Diagnosis
Directions:
Indicate your final diagnosis (
ONE
ONLY). Include your diagnostic reasoning with rationale: provide clear clinical justification, correlate subjective and objective findings, and explain why competing diagnoses are less likely.
Part III, Section 3: Final Problem Statement
Directions:
Use the template below to write a final, synthesized problem statement.
[Initials/Name], [Age], presents with [chief complaint] characterized by [positive subjective findings] and denies [negative subjective findings]. Physical exam reveals [positive objective findings] with absence of [negative objective findings]. Pertinent history includes [relevant PMH, family history, or risk factors]. The overall clinical picture is most consistent with [final diagnosis].
Part IV: Reflection
This reflection is designed to strengthen your clinical reasoning and your ability to clearly separate subjective and objective data in documentation.
Part IV, Section 1: Subjective vs. Objective Distinction
Identify one example in your documentation where it was challenging to separate subjective and objective data.
Explain how you ensured patient-reported symptoms remained in the history/ROS and observable findings remained in the physical exam.
Briefly explain why this distinction is important for diagnostic accuracy.
Part IV, Section 2: Diagnostic Reasoning
Identify one differential diagnosis you strongly considered but ultimately ruled out.
List
two
key findings (pertinent positives or negatives) that helped you rule it out.
State what finding most strongly supported your final diagnosis.
References
List 3–5 peer-reviewed references, less than 5 Years Old. Cite all sources in APA format.
Simulation Case Study #3: Gastrointestinal Complaint – Reflux Symptoms
This simulation assignment allows you to demonstrate advanced clinical reasoning by conducting a comprehensive health history and physical examination followed by the development of an accurate assessment that includes differential and final diagnoses NURS-6512 week 7 Angela Brooks. You will apply a systematic approach to identify normal and abnormal findings, support diagnostic reasoning with evidence-based guidelines, and document clearly using professional standards.
Level 1: No AI Permitted
AI tools may
not
be used at any stage
Common for clinical documentation or performance‑based work
Resources
Be sure to review the Learning Resources before completing this assessment.
Required Resources
To prepare:
Download and review both the “
Comprehensive Health History Reference Sheet”
Download Comprehensive Health History Reference Sheet”
, “
Physical Exam Reference Sheet
Download Physical Exam Reference Sheet
”, and the “
Assessment Reference Sheet
Download Assessment Reference Sheet
.”
Access
Simulation Case Study #3: Gastrointestinal ComplaintLinks to an external site.
.
Review current evidence-based guidelines related to the patient complaint.
Download the Assignment Template
Download Download the Assignment Template
.
The Assignment (Template)
This assignment requires you to document:
Comprehensive health history (subjective data)
Focused physical examination (objective data)
Development of at least three differential diagnoses
Identification of one primary diagnosis
Diagnostic reasoning with rationale
A final synthesized problem statement
PART I: Comprehensive Health History (Subjective Data Only)
Include:
Identifying data
Chief complaint
HPI written as a cohesive OLDCARTS narrative
Medications
Past medical history
Surgical history
Family history
Preventive screenings
Social history and SDOH
Focused ROS
You must document expected findings in the ROS based on your clinical reasoning. ROS must remain
subjective only
.
PART II: Focused Physical Examination (Objective Data Only)
You must document expected objective findings consistent with your assessment and differential considerations. Expand your finding results as appropriate by identifying and documenting expected findings. You may include your
own
version of findings 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 III: Assessment and Diagnostic Reasoning
Part III, Section 1: Differential Diagnoses
You must include a minimum of
three
differential diagnoses and one final (primary) diagnosis.
For each differential diagnosis:
Provide pathophysiologic explanation
Identify pertinent positives
Identify pertinent negatives
Explain why it is ruled in or ruled out
Part III, Section 2: One Primary Diagnosis
For the primary diagnosis:
Provide clear clinical justification
Correlate subjective and objective findings
Explain why competing diagnoses are less likely
Part III, Section 3: Final Problem Statement
Conclude your assessment with a synthesized problem statement using the template provided.
Documentation Expectations
You must:
Clearly separate subjective and objective data
Use appropriate medical terminology
Demonstrate systematic and logical reasoning
Support all diagnostic conclusions with pertinent positives and negatives
Present professional, graduate-level documentation
Ensure the final problem statement reflects clinical synthesis rather than repetition
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:
Evaluation of GERD
Differentiation of GI versus cardiac chest pain
Diagnostic criteria and risk factors
Clinical reasoning in primary care
Acceptable Sources:
Peer-reviewed journal articles
American College of Gastroenterology (ACG) guidelines
Evidence-based advanced practice nursing texts
CDC or WHO clinical documents
Unacceptable Sources:
Patient education websites (Mayo Clinic, Cleveland Clinic, WebMD, Healthline)
Wikipedia
Blogs or commercial websites
All references must be cited in APA format.
Part IV: Reflection (1–2 pages in Template)
After completing
Parts I, II, and III
, submit a reflection addressing the prompts provided in the assignment template. This reflection is designed to strengthen your clinical reasoning and your ability to clearly separate subjective and objective data in documentation.
By Sunday of Week 7
Submit the Assignment.
Submission Information
Before submitting your final NURS-6512 week 7 Angela Brooks assignment, you can check your draft for authenticity. To check your draft, access the
Turnitin Drafts
from the
Start Here
area.
To submit your completed assignment, save your Assignment as
MD3Assgn2_LastName_FirstInitial
Then, click on
Start Assignment
near the top of the page.
Next, click on
Upload File
and select
Submit Assignment
for review.
NURS-6512 week 7 Angela Brooks Rubric
NURS_6512_Module3_Assignment2_Rubric
NURS_6512_Module3_Assignment2_Rubric
Criteria
Ratings
Pts
This criterion is linked to a Learning OutcomePart I: Comprehensive Health History (Subjective Data Only)… Demonstrates accurate and complete documentation of patient comprehensive health history (subjective data only, including review of systems) NURS-6512 week 7 Angela Brooks.
15 to >13.41 ptsExcellent
Provides accurate and complete documentation of patient comprehensive health history (subjective data only, including patient-reported symptoms).
13.41 to >11.91 ptsGood
Provides a mostly accurate and complete patient comprehensive health history (subjective data only, including patient-reported symptoms); may contain some minor errors.
11.91 to >0 ptsPoor
Does not provide documentation of patient health history (subjective data only, including patient-reported symptoms); documentation is inaccurate and/or incomplete.
15 pts
This criterion is linked to a Learning OutcomePart II: Focused Physical Examination (Objective Data Only)… Demonstrates accurate and complete documentation of patient focused physical examination (objective data only).
15 to >13.41 ptsExcellent
Provides accurate and complete documentation of patient focused physical examination (objective data only).
13.41 to >11.91 ptsGood
Provides a complete, mostly accurate documentation of patient focused physical examination (objective data only); may contain some minor errors.
11.91 to >0 ptsPoor
Does not provide documentation of patient focused physical examination (objective data only); data provided is inaccurate and/or incomplete.
15 pts
This criterion is linked to a Learning OutcomePart III: Assessment and Diagnostic Reasoning… Part III, Section 1: Three Differential Diagnoses… For each differential diagnosis, provide pathophysiologic explanation, identify pertinent positives, identify pertinent negatives, explain why it is ruled in or ruled out.
15 to >13.41 ptsExcellent
Provides three fully developed and accurate differential diagnoses.
13.41 to >11.91 ptsGood
Provides three adequately developed and accurate differential diagnoses.
11.91 to >0 ptsPoor
Does not provide three differential diagnoses; the diagnoses provided are inaccurate or incomplete.
15 pts
This criterion is linked to a Learning OutcomePart III: Assessment and Diagnostic Reasoning… Part III, Section 2: One Primary Diagnosis… Indicate your final diagnosis (ONE ONLY). Include your diagnostic reasoning with rationale: provide clear clinical justification, correlate subjective and objective findings, and explain why competing diagnoses are less likely.
10 to >8.94 ptsExcellent
Provides correct primary diagnoses including a fully developed diagnostic reasoning with rationale.
8.94 to >7.94 ptsGood
Provides correct primary diagnoses including an adequately developed diagnostic reasoning with rationale.
7.94 to >0 ptsPoor
Does not provide correct primary diagnosis; diagnostic reasoning is incorrect, incomplete, or inaccurate.
10 pts
This criterion is linked to a Learning OutcomePart III: Assessment and Diagnostic Reasoning… Part III, Section 3: Final Problem Statement… Write a final, synthesized problem statement.
10 to >8.94 ptsExcellent
Provides one fully developed and accurate final problem statement.
8.94 to >7.94 ptsGood
Provides an adequately developed and mostly accurate final problem statement.
7.94 to >0 ptsPoor
Does not provide a final problem statement; final problem statement is incomplete or inaccurate.
10 pts
This criterion is linked to a Learning OutcomePart IV: Reflection… Part IV, Section 1: Subjective vs. Objective Distinction… Identify one example in your documentation where it was challenging to separate subjective and objective data; Explain how you ensured patient-reported symptoms remained in the history/ROS and observable findings remained in the physical exam. Briefly explain why this distinction is important for diagnostic accuracy.
10 to >8.94 ptsExcellent
Provides a fully developed reflection that identifies one example in their documentation where it was challenging to separate subjective and objective data, explains how they ensured patient-reported symptoms remained in the history/ROS and observable findings remained in the physical exam, and briefly explains why this distinction is important for diagnostic accuracy.
8.94 to >7.94 ptsGood
Provides an adequately developed reflection that identifies one example in their documentation where it was challenging to separate subjective and objective data, explains how they ensured patient-reported symptoms remained in the history/ROS and observable findings remained in the physical exam, and briefly explains why this distinction is important for diagnostic accuracy.
7.94 to >0 ptsPoor
Does not provide a reflection on subjective vs. objective data distinction; reflection is unclear or incomplete.
10 pts
This criterion is linked to a Learning OutcomePart IV: Reflection… Part IV, Section 2: Diagnostic Reasoning…Identify one differential diagnosis you strongly considered but ultimately ruled out; List two key findings (pertinent positives or negatives) that helped you rule it out; State what finding most strongly supported your final diagnosis NURS-6512 week 7 Angela Brooks.
10 to >8.94 ptsExcellent
Provides a fully developed reflection that identifies one differential diagnosis they strongly considered but ultimately ruled out, lists two key findings (pertinent positives or negatives) that helped them rule it out, and states what finding most strongly supported their final diagnosis.
8.94 to >7.94 ptsGood
Provides an adequately developed reflection that identifies one differential diagnosis they strongly considered but ultimately ruled out, lists two key findings (pertinent positives or negatives) that helped them rule it out, and states what finding most strongly supported their final diagnosis.
7.94 to >0 ptsPoor
Does not provide a reflection on diagnostic reasoning; reflection is unclear or incomplete.
10 pts
This criterion is linked to a Learning OutcomeUses at least 3 scholarly resources that are less than 5 years old.
5 to >4.46 ptsExcellent
Uses 3 peer-reviewed scholarly sources published within the last 5 years.
4.46 to >3.96 ptsGood
Uses 2 peer-reviewed scholarly sources published within the last 5 years.
3.96 to >3.46 ptsFair
Uses 1 peer-reviewed scholarly source published within the last 5 years.
3.46 to >0 ptsPoor
Does not use peer-reviewed scholarly sources or sources used are older than 5 years.
5 pts
This criterion is linked to a Learning OutcomeSource Attribution and APA Formatting
5 to >4.46 ptsExcellent
All sources are cited in APA format without any errors.
4.46 to >3.96 ptsGood
All sources are cited in APA format with some minor errors.
3.96 to >3.46 ptsFair
All sources are cited with frequent APA formatting errors.
3.46 to >0 ptsPoor
Missing source citations and/or minimal adherence to APA formatting rules.
5 pts
This criterion is linked to a Learning OutcomeGrammar, Mechanics, and Punctuation
5 to >4.46 ptsExcellent
Correct grammar, spelling, and punctuation with no errors.
4.46 to >3.96 ptsGood
Correct grammar, spelling, and punctuation with few errors.
3.96 to >3.46 ptsFair
Correct grammar, spelling, and punctuation with frequent errors.
3.46 to >0 ptsPoor
Frequent errors in grammar, spelling, and punctuation that interfere with comprehension.
5 pts
Total Points: 100 NURS-6512 week 7 Angela Brooks
