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. 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

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.

To prepare:

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 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.

By Sunday of Week 7

Submit the Assignment.

Submission Information

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Rubric

NURS_6512_Module3_Assignment2_Rubric
NURS_6512_Module3_Assignment2_Rubric
Criteria Ratings Pts
Part 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
Part 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
Part 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
Part 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
Part 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
Part 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
Part 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
Uses 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
Source 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
Grammar, 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