NURS 6512 Week 7 Angela Brooks Simulation Case Study: Burning in Chest After Eating

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