NURS 6512 Health Assessment Module 3 Week 7 Assignment

NURS 6512 Health Assessment Module 3 Week 7 Assignment

Comprehensive Health History, Physical Examination, and Assessment Template

Part I: Comprehensive Health History (Subjective Data Only)

Subjective Data

Chief Complaint (CC): “Burning in the middle of my chest after I eat.

History of Present Illness (HPI): The patient, A.B, is a 52-year-old African American divorced woman who works as a real estate agent, has private health insurance and resides alone. She states she has been experiencing a burning sensation in the middle of her chest for 3 to 4 months, 30 to 60 minutes after eating, particularly after eating spicy/fried foods. She says the pain is a 5/10, and food gets regurgitated into the throat. She also reports a sour taste in the mouth. Patient becomes uncomfortable while lying in bed during the night and has been propping herself up with pillows. She also complains of frequent throat clearing in the morning. Symptoms recur, but can be partially relieved with OTC antacids. She does not complain of difficulty breathing, sweating, arm or jaw pain, vomiting, blood vomiting or weight loss.

Past Medical History (PMH):  No history of previous medical issues

Surgical History (PSH): No prior surgeries

Medications: OTC antiacids as required

Allergies: No known allergies reported

Preventive Health: Patient didn’t provide preventative screening history.

Social History: Patient is divorced and lives alone. She works in the real estate industry as an agent. Drinks coffee every other morning and a glass of wine several times. Patient has increased stress and reports eating frequently in a restaurant.

Review of Systems (ROS) (Subjective Data Only – Patient-Reported Symptoms):

General: Denies fatigue, weight loss, or fever

Skin: Denies jaundice or rash.

HEENT: Reports sour tastes in her mouth and also frequent clearing of throat.

Cardiac: Denies palpitations, exertional chest pain, arm pain, diaphoresis or jaw pain.

Respiratory: Denies wheezing, shortness of breath, or cough.

Gastrointestinal (GI): Reports postprandial burning chest discomfort, regurgitation, and worsening symptoms when lying down. Rejects the presence of vomiting, nausea, hematemesis, dysphagia or melena.

Genitourinary (GU): Rejects dysuria, urinary frequency or hematuria.

Musculoskeletal (MSK): Rejects having generalized joint pain or chest wall injury

Neurologic: Rejects headache, dizziness, syncope, or weakness.

Psychiatric: States that they have stress associated with work and eating outside the house.

Endocrine: Denies heat/cold intolerance, polyuria, or polydipsia

Hematologic/Lymphatic/Immune: Denies recurrent infections, easy bruising, or bleeding

Part II: Focused Physical Examination (Objective Data Only)

Physical Examination: Objective Data Only (Do NOT include subjective statements):

General: The patient is pleasant, well-organized and kind. Well-dressed, responds to questions but looks weary.

Skin: Dry, warm, intact, no rash or jaundice

Head: Normocephalic, atraumatic

Eyes: Sclera anicteric, clear conjunctiva,

Ears: Normal external ears

Nose: Pink nasal mucosa minus discharge

Mouth/Throat: Moist oral mucosa, lesions non-existent, no exudate or erythema in posterior pharynx,

Neck: Trachea midline, supple, minus cervical lymphadenopathy

Cardiac: Rate and rhythm regular; rubs, gallops or murmurs non-existent

Lungs: Clear to auscultation; rhonchi, wheezes, or rales nonexistent.

Abdomen: Soft, nondistended. Palpitation reveals mild epigastric tenderness; lacks palpable mass, guarding, or rebound.

Genitourinary (GU): Deferred

Musculoskeletal: Chest wall tenderness lacking; full ROM; posture is normal

Lower Extremities: No calf tenderness, edema, or cyanosis

Neurologic: Alert and oriented, clear speech , without focal deficits.

 

 

Part III: Assessment and Diagnostic Reasoning

Part III, Section 1: Three Differential Diagnoses

Differential Diagnosis #1:

Condition: Gastroesophageal reflux disease (GERD)

Rationale: The condition occurs when contents in the gastric section of the stomach reflux into the esophagus as a result of a dysfunction in the lower esophageal sphincter, which leads to heartburn and regurgitation (Marine et al., 2024). The patient reveals classic symptoms, which occur immediately after meals and worsen when she lies down. Furthermore, they only improve, albeit temporarily, after she takes antacids.

Pertinent positives and negatives: The positives include burning discomfort in the middle of the chest after meals, sour taste, regurgitation, nocturnal worsening, throat clearing, and partial relief when she takes antacids (Hossa & Małecka-Wojciesko, 2025). The negatives include lack of diaphoresis, dyspnea, weight loss, hematemesis, vomiting, and jaw or arm radiation.

It is ruled in because the pattern of the symptoms align with uncomplicated GERD and does not have alarming features.

Differential Diagnosis #2:

Condition: Peptic ulcer disease / dyspepsia

Rationale: The condition can lead to major gastrointestinal discomfort and may also respond to antacids or acid suppression. It may be a diagnosis in this situation since the upper abdominal pain related to meals or even the discomfort in the patient’s chest may overlap with reflux symptoms.

Pertinent positives and negatives: The positives include upper epigastric/chest discomfort as well as transient enhancements with the antacids (Almadi et al., 2024). The negatives include lack of vomiting, hematemesis, melena, or severe epigastric pain persistently.

This is ruled out because the presence of sour taste, regurgitation, and worsening of symptoms when supine is indicative of GERM the more likely diagnosis.

Differential Diagnosis #3:                                  

Condition: Cardiac chest pain / angina

Rationale: Burning sensation in the chest may be due to ischemic pain and as such, cardiac causes should be considered. This is particularly true when the patient who complains of chest pain is an adult. However, the presence of pain after exertion may be related to diaphoresis, dyspnea or radiation to the jaw or arm.

Pertinent positives and negatives: The positives include chest discomfort whilst the negatives include lack of exertional component, jaw or pain, acute distress, diaphoresis, and shortness of breath (Rinaldi et al., 2025).

Part III, Section 2: One Primary Diagnosis

Directions: Gastroesophageal reflux disease (GERD)

The primary diagnosis of the patient’s situation is GERD since the symptoms are associated with acid reflux. The burning discomfort that occurs after she eats, sour taste in her mouth, and the worsening of symptoms when she lies down are all indicative of GERD. Further, the fact that her antacid resolves the pain indicates the existence of acid-mediated pathology caused by GERD. Moreover, the absence of alarms symptoms as well as cardiac red flags similarly supports the diagnosis of GERD. However, the cardiac chest pain and peptic ulcer disease are inconsistent with the presentation.

 

Part III, Section 3: Final Problem Statement

Angela Brooks, 52, presents with burning chest discomfort after eating characterized by postprandial mid-chest burning, regurgitation, sour taste, and worsening when lying down, and denies shortness of breath, diaphoresis, arm or jaw pain, vomiting, hematemesis, and weight loss. Physical examination reveals a well-appearing woman with stable cardiopulmonary findings, a soft abdomen with mild epigastric tenderness, and no acute distress. Pertinent history includes coffee intake, wine use, frequent spicy and fried foods, stress, and partial relief with antacids. The overall clinical picture is most consistent with gastroesophageal reflux disease.

Part IV: Reflection

 

Part IV, Section 1: Subjective vs. Objective Distinction

Separation of objective and subjective data in an assessment is a fundamental aspect of clinical diagnosis. In this particular case, it was challenging to separate the subjective and objective nature of the patient’s throat clearing and sour taste symptoms. In order to make the distinction, both symptoms remained in the HPI and ROS since they were reported by the patient whilst at the same time ensuring that findings such as mild epigastric tenderness, regular heart rhythm, and clear lungs were reserved for the physical exam. The distinction is significant since separating the objective and subjective data clearly leads to improvement in accuracy, enhances sound clinical reasoning and also prevents misleading documentation information.

 

Part IV, Section 2: Diagnostic Reasoning

1. Identify one differential diagnosis you strongly considered but ultimately ruled out.

Cardiac chest pain.

2. List two key findings (pertinent positives or negatives) that helped you rule it out.

• Lack of exertional symptoms
• Absence of arm or jaw radiation, shortness of breath or diaphoresis.

 

3. State what finding most strongly supported your final diagnosis.

The reflux pattern of burning sensation was the finding that strongly supported the final diagnosis. This is particularly important since it occurred immediately after meals and worsened when the patient was lying down (Hossa & Małecka-Wojciesko, 2025). In addition, regurgitation and sour taste similarly supported the diagnosis.

 

 

References        

Almadi, M. A., Lu, Y., Alali, A. A., & Barkun, A. N. (2024). Peptic ulcer disease. The Lancet, 404(10447), 68–81. https://doi.org/10.1016/S0140-6736(24)00155-7

Hossa, K., & Małecka-Wojciesko, E. (2025). Advances in gastroesophageal reflux disease management: Exploring the role of potassium-competitive acid blockers and novel therapies. Pharmaceuticals, 18(5), 699. https://doi.org/10.3390/ph18050699

Marines, E. J., Casipit, C. G. C., Idowu, A., Obomanu, E., Mehadi, A. Y., Robinson, K., Anebo, T., Suenghataiphorn, T., Yadete, T., Wattanachayakul, P., Srikulmontri, T., Isaacs, E., Davis, M. L., Carty, J., Byfield, K., Tahir, H., Ibe, F. O., Jones, C. F., Balogun, O., & Deepali, F. (2024). S633 Gastroesophageal Reflux Disease (GERD) and Risk of Incident Acute Myocardial Infarction: A Systematic Review and Meta-analysis of Cohort Studies. American Journal of Gastroenterology, 119(10S), S438-S439. https://doi.org/10.14309/01.ajg.0001031900.55302.bd

Rinaldi, R., Kunadian, V., Crea, F., & Montone, R. A. (2025). Management of angina pectoris. Trends in Cardiovascular Medicine, 35(6), 341–350. https://doi.org/10.1016/j.tcm.2025.03.001pubmed.ncbi.nlm.nih

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To prepare:

• Download and review both the “Comprehensive Health History Reference Sheet”Download Comprehensive Health History Reference Sheet”, “Physical Exam Reference SheetDownload Physical Exam Reference Sheet”, and the “Assessment Reference SheetDownload 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 TemplateDownload 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 1: COMPREHENSIVE HEALTH HISTORY (SUBJECTIVE DATE 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 2: FOCUSED PHYSICAL EXAMINATION (OBJECTIVE DATE 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 3: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  (MUST INCLUDE ARTICLE NOT JUST CDC OR WHO)

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 4: 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