week 7 case study
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REQUIRED EESOURCES:
NOTE: Utilize this text as a clinical reference to aid your analysis for the relevant areas noted. Also utilize study questions to develop your understanding of the concepts and topics presented throughout this course.
· Soriano, R. P. (2026). Bates’ guide to physical examination and history taking(14th ed.). Wolters Kluwer Health.
· Chapter 21, "Abdomen"
· Chapter 22, "Anus and Rectum"
· Harvard, M. G., & Mulligan, B. (2023, June). Acute abdominal pain in adults. American Family Physician Links to an external site. . https://www.aafp.org/pubs/afp/issues/2023/0600/acute-abdominal-pain-adults.html
· American College of Radiology. (n.d.). Appropriateness Criteria Links to an external site. . https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria
· Document: Comprehensive Health History Reference Sheet (PDF) Download Comprehensive Health History Reference Sheet (PDF)
· Document: Physical Exam Reference Sheet (PDF) Download Physical Exam Reference Sheet (PDF)
· Document: Assessment Reference Sheet (PDF) Download Assessment Reference Sheet (PDF)
· Document: Week 7 Assignment Template (Word) Download Week 7 Assignment Template (Word)
· Walden University, LLC. (n.d.). Simulation case study #3: Gastrointestinal complaint – Reflux Symptoms Links to an external site. . Walden University Canvas. https://waldenu.instructure.com
INSTRUCTIONS:
· 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:
1. Comprehensive health history (subjective data)
2. Focused physical examination (objective data)
3. Development of at least three differential diagnoses
4. Identification of one primary diagnosis
5. Diagnostic reasoning with rationale
6. 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.
RUBRIC:
NURS_6512_Module3_Assignment2_Rubric
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NURS_6512_Module3_Assignment2_Rubric |
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Criteria |
Ratings |
Pts |
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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). |
15 to >13.41 ptsExcellentProvides accurate and complete documentation of patient comprehensive health history (subjective data only, including patient-reported symptoms). 13.41 to >11.91 ptsGoodProvides 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 ptsPoorDoes not provide documentation of patient health history (subjective data only, including patient-reported symptoms); documentation is inaccurate and/or incomplete. |
15 pts |
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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 ptsExcellentProvides accurate and complete documentation of patient focused physical examination (objective data only). 13.41 to >11.91 ptsGoodProvides a complete, mostly accurate documentation of patient focused physical examination (objective data only); may contain some minor errors. 11.91 to >0 ptsPoorDoes not provide documentation of patient focused physical examination (objective data only); data provided is inaccurate and/or incomplete. |
15 pts |
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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 ptsExcellentProvides three fully developed and accurate differential diagnoses. 13.41 to >11.91 ptsGoodProvides three adequately developed and accurate differential diagnoses. 11.91 to >0 ptsPoorDoes not provide three differential diagnoses; the diagnoses provided are inaccurate or incomplete. |
15 pts |
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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 ptsExcellentProvides correct primary diagnoses including a fully developed diagnostic reasoning with rationale. 8.94 to >7.94 ptsGoodProvides correct primary diagnoses including an adequately developed diagnostic reasoning with rationale. 7.94 to >0 ptsPoorDoes not provide correct primary diagnosis; diagnostic reasoning is incorrect, incomplete, or inaccurate. |
10 pts |
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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 ptsExcellentProvides one fully developed and accurate final problem statement. 8.94 to >7.94 ptsGoodProvides an adequately developed and mostly accurate final problem statement. 7.94 to >0 ptsPoorDoes not provide a final problem statement; final problem statement is incomplete or inaccurate. |
10 pts |
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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 ptsExcellentProvides 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 ptsGoodProvides 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 ptsPoorDoes not provide a reflection on subjective vs. objective data distinction; reflection is unclear or incomplete. |
10 pts |
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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. |
10 to >8.94 ptsExcellentProvides 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 ptsGoodProvides 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 ptsPoorDoes not provide a reflection on diagnostic reasoning; reflection is unclear or incomplete. |
10 pts |
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This criterion is linked to a Learning OutcomeUses at least 3 scholarly resources that are less than 5 years old. |
5 to >4.46 ptsExcellentUses 3 peer-reviewed scholarly sources published within the last 5 years. 4.46 to >3.96 ptsGoodUses 2 peer-reviewed scholarly sources published within the last 5 years. 3.96 to >3.46 ptsFairUses 1 peer-reviewed scholarly source published within the last 5 years. 3.46 to >0 ptsPoorDoes not use peer-reviewed scholarly sources or sources used are older than 5 years. |
5 pts |
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This criterion is linked to a Learning OutcomeSource Attribution and APA Formatting |
5 to >4.46 ptsExcellentAll sources are cited in APA format without any errors. 4.46 to >3.96 ptsGoodAll sources are cited in APA format with some minor errors. 3.96 to >3.46 ptsFairAll sources are cited with frequent APA formatting errors. 3.46 to >0 ptsPoorMissing source citations and/or minimal adherence to APA formatting rules. |
5 pts |
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This criterion is linked to a Learning OutcomeGrammar, Mechanics, and Punctuation |
5 to >4.46 ptsExcellentCorrect grammar, spelling, and punctuation with no errors. 4.46 to >3.96 ptsGoodCorrect grammar, spelling, and punctuation with few errors. 3.96 to >3.46 ptsFairCorrect grammar, spelling, and punctuation with frequent errors. 3.46 to >0 ptsPoorFrequent errors in grammar, spelling, and punctuation that interfere with comprehension. |
5 pts |
Total Points: 100
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.