Discuss the importance of creating a list of differentials for this patient. How could it have changed this outcome?

/in /by

Relying solely on the classic features of a disease may be misleading. That’s because the clinical presentation of a disease often varies: the symptoms and signs of many conditions are non-specific initially and may require hours, days, or even months to develop.

Generating a differential diagnosis; that is, developing a list of the possible conditions that might produce a patient’s symptoms and signs — is an important part of clinical reasoning. It enables appropriate testing to rule out possibilities and confirm a final diagnosis.

This case portrays a poor patient outcome after a misdiagnosis.

Case scenario

A previously healthy 35-year-old lawyer presents to a primary care office with a chief complaint of chest pain and a non-productive cough. The pain started suddenly 2 hours prior to coming to the office while the patient was sitting at his desk. The patient describes the pain as sharp in nature, constantly present but made worse with inspiration and movement, and with radiation to the base of the neck. His blood pressure in the right arm and other vital signs are normal.

On physical examination the only findings of note are chest wall tenderness and a faint cardiac murmur. The ECG in the office is normal. The patient is observed for an hour in the office and assessed. He is diagnosed with viral pleurisy and sent home on non-steroidal analgesics.

The following day the patient collapses at home and cannot be resuscitated by the paramedic service. An autopsy reveals a Type 1 aortic dissection with pericardial tamponade.

Written Assignment:

Developing a list of possible conditions that might produce a patient’s symptoms and signs is an important part of clinical reasoning.

As an NP in primary care what would you have done differently?

Discuss the importance of creating a list of differentials for this patient. How could it have changed this outcome?

If a serious diagnosis comes to mind based on a patient’s symptoms:

Ask yourself; Have you considered the likelihood of it and whether it needs to be ruled out by testing or referral?

Because many serious disorders are challenging to diagnose, have you considered ruling out the worst case scenario?

Ask yourself: Do you have sufficient understanding of the clinical presentation to offer an opinion on the diagnosis?

What other diagnosis could it be? How might the treatment to date have altered the patient outcome?

What other diagnostic and laboratory or imaging was needed in order to make a complete differential list?

What support tools would you consider using in helping to create a differential diagnosis list?

Are you familiar with the current clinical practice guidelines for the investigation of a suspected condition such as chest pain?

Which of the following is a sign or symptom of cauda equina compression?

/in /by

Question 2: CPT coding offers the uniformed language used for reporting medical services and procedures performed by physician and nonphysician practitioners. Clinicians are paid based on calculated resource costs that are calculated based on practice components.

a. Clinician education loans
b. Clinician practice liability and malpractice expense
c. Clinician reported cost reduction efforts
d. Clinician volume of patients treated

Question 3: Janet is a 30-year-old woman who has been recently diagnosed with a herniated disc at the level of L5-S1. She is currently in the emergency room with suspicion of cauda equina compression.
Which of the following is a sign or symptom of cauda equina compression?
a. Gastrocnemius weakness
b. A reduced or absent ankle reflex
c. Numbness in the lateral foot
d. Paresthesia of the perineum and buttocks

Question 4: A 58-year-old woman who had a total abdominal hysterectomy at the age of 45 is diagnosed with atrophic vaginitis. Which of the following is the most appropriate treatment?
a. Conjugated estrogen 0.625 mg/day oral
b. Estradiol 7.5 mcg/24 hr vaginal ring
c. Medroxyprogesterone 10 mg/day oral
d. Conjugated estrogen 0.3 mg + medroxyprogesterone 1.5 mg/day oral

Question 5: Which of the following is a specific test for multiple sclerosis (MS)?

a. Magnetic resonance imaging (MRI)
b. Computed tomography (CT) scan
c. A lumbar puncture
d. There is no specific test.

Question 6: Most adult poisonings are:

a. intentional and self-inflicted.
b. accidental.
c. caused by someone wishing to do harm to the person.
d. not attributed to any reason.

Question 7: A 60-year-old man presents with an enlarged scrotum. The clinician uses a penlight to transilluminate the scrotum. In a patient with a hydrocele, what would the clinician expect to find?

a. The scrotum will be dark.
b. The scrotum will appear light pink or yellow.
c. The scrotum will appear milky white.
d. The internal structures will be clearly visible.

Question 8: Which clinical feature is the first to be affected in increased intracranial pressure (ICP)?What is the normal number for the Glascow Coma Scale?

a. 7

b. 9

c. 10
d. 15

Question 9: S presents in the clinic with pain, tenderness, erythema, and swelling of his left great toe. The clinician suspects acute gout. Which of the following should the clinician suspect in the initial test results for this patient?

a. Elevated uric acid level
b. Elevated blood urea nitrogen (BUN)
c. Decreased urine pH
d. Decreased C-reactive protein (CRP)

Question 10: Which solution should be used when irrigating lacerated tissue over a wound on the arm?

a. Dilute povidone-iodine solution
b. Hydrogen peroxide (H2O2)
c. Saline solution infused with an antibiotic
d. Saline irrigation or soapy water

Question 11: Which ethical principle reflects respect for all persons and their self-determination?

a. Autonomy

b. Beneficence

c. Justice
d. Veracity

Question 12: During a digital rectal exam (DRE) on a 75-year-old man, the clinician suspects the patient has prostate cancer. What physical finding should make the clinician suspicious?

a. An enlarged rubbery gland

b. A hard irregular gland

c. A tender gland
d. A boggy gland

Question 13: How often should the clinician examine the feet of a person with diabetes?

a. Once a year
b. Every 6 months
c. Every 3 months
d. Every visit

Question 14: Which of the following medications is the treatment of choice for trichomonas? (Points: 2)

a. Metranidazole

b. Ceftriaxone

c. Diflucan
d. Doxycycline

Question 15: Immunizations are an example of which type of prevention? (Points: 2)

a. Primary
b. Secondary
c. Tertiary

Question 16: What is the treatment of choice for a patient diagnosed with testicular cancer?

a. Radical orchidectomy

b. Lumpectomy

c. Radiation implants
d. All of the above

Question 17: George, aged 59, complains of a flulike illness, including fever, chills, and myalgia after returning from visiting his grandchildren in New England. He reports having discovered a rash or red spot that grew in size on his right leg. What disease are you considering?

a. A viral syndromes
b. Lyme disease
c. Rocky Mountain spotted fever
d. Relapsing fever

Question 18: A 24-year-old woman presents to the clinic with dysuria, dyspareunia, and a mucopurulent vaginal discharge. Her boyfriend was recently treated for nongonococcal urethritis. What sexually transmitted disease (STD) has she most probably been exposed to?
a. Gonorrhea
b. Human papillomavirus (HPV)
c. Chlamydia
d. Trichomonas

Question 19: What is usually the first sign or symptom that a patient would present with that would make you suspect herpes zoster?

a. A stabbing type of pain on one small area of the body
b. A vesicular skin lesion on one side of the body
c. A pain that is worse upon awakening
d. A lesion on the exterior ear canal

Question 20: Which drug commonly prescribed for burns is active against a wide spectrum of microbial pathogens and is the most frequently used agent for partial- and full-thickness thermal injuries?
a. Clotrimazole cream (Lotrimen)
b. Mafenide acetate (Sulfamylon)
c. Silver nitrate
d. Silver sulfadiazine (Silvadene)

Question 21: Which of the following is a role of the advanced practice nurse in palliative cancer care?

a. Detecting cancer in asymptomatic patients or those with specific symptoms
b. Arranging for follow-up care, including psychosocial and spiritual support
c. Identifying and managing complications of care
d. All of the above

Question 22: Which type of burn injury results in destruction of epidermis with most of the dermis, yet the epidermal cells lining hair follicles and sweat glands remain intact?

a. Superficial burns
b. Superficial partial-thickness burns
c. Deep partial-thickness burns
d. Full-thickness burns

Question 23: The criteria for diagnosing generalized anxiety disorder in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (text revision) (DSM-IV-TR) state that excessive worry or apprehension must be present more days than not for at least:

a. 1 month.
b. 3 months.
c. 6 months.
d. 12 months.

Question 24: In the United States, what is the second most common connective tissue disease and the most destructive to the joints?

a. Osteoarthritis
b. Systemic lupus erythematosus (SLE)
c. Rheumatoid arthritis (RA)
d. Sjogren’s syndrome

Identify one statistical analysis method that you found recurring in many of the articles you used in your literature review for your research proposal. This method does not necessarily have to be nonparametric

/in /by

Review the articles presented in this week’s Learning Resources and analyze each study’s use of nonparametric tests.

Critically analyze each article, considering the following questions in your analysis:

What are the goals and purpose of the research study each article describes?

How are nonparametric tests used in each study? What are the results of their use?

Why are parametric methods (t tests and ANOVA) inappropriate for the statistical analysis of each study’s data?

What are the strengths and weaknesses of each study (e.g., study design, sampling, and measurement)?

How could the findings and recommendations of each study contribute to evidence-based practice in the health care field?

Reflect on the quantitative statistical analyses presented throughout this course in the research literature, the Learning Resources, media presentations, and those articles you reviewed for your abbreviated research proposal.

Ask yourself: Which method is most commonly used in research studies that pertain to my area of nursing practice, and why this might be so?

TO COMPLTE

Post 1-2 PAGES PAPER ON : A cohesive response addresses the following:

Critically analyze each article, including the items noted above.

Identify one statistical analysis method that you found recurring in many of the articles you used in your literature review for your research proposal. This method does not necessarily have to be nonparametric.

Based on your area of nursing practice ( family Nurse Practitioner) , which method of statistical analysis is most frequently used in the research literature? Why do you think other forms of statistical analysis are less frequently used? Provide a rationale for your response.

References

Gray, J.R., Grove, S.K., & Sutherland, S. (2017). Burns and Grove’s the practice of nursing research: Appraisal, synthesis, and generation of evidence (8th ed.). St. Louis, MO: Saunders Elsevier.

Chapter 25, “Using Statistics to Determine Differences”

Chapter 8, “Chi-Square and Nonparametric Tests”

See these attached articles :

Fisher, K., Orkin, F., & Frazer, C. (2010). Utilizing conjoint analysis to explicate health care decision making by emergency department nurses: A feasibility study. Applied Nursing Research, 23(1), 30–35. doi:10.1016/j.apnr.2008.03.

Tjia, J., Field, T., Garber, L., Donovan, J., Kanaan, A., Raebel, M., … Gurwitz, J. (2010). Development and pilot testing of guidelines to monitor high-risk medications in the ambulatory setting. American Journal of Managed Care, 16(7), 489–496.

Development and pilot testing of guidelines to monitor high-risk medications in the ambulatory setting. American Journal of Managed Care, 16(7) by Tjia, J., Field, T., Garber, L., Donovan, J., Kanaan, A., Raebel, M., & Gurwitz, J. Copyright 2010 by INTELLISPHERE, LLC. Reprinted by permission of INTELLISPHERE, LLC via the Copyright Clearance Center.

Describe a problem, issue, or situation that you have observed during your Practicum Experience (no more than a half page).

/in /by

This week, you complete and submit your second journal entry. Your journal draws from evidence, concepts, and/or theories you have examined in this program, especially those related to your specialization. What have you observed during your Practicum Experience that you would like to analyze through your journal writing?

To prepare:
  • Reflect on your Practicum Experiences in Weeks 4-7.
  • Think about the evidence, concepts, and/or theories (evidence) learned throughout this program and your specialization.
  • Analyze a problem, issue, or situation that you have observed during your Practicum Experience.
  • Using a minimum of three peer-reviewed sources of evidence, consider what you have observed within the context of your specialty using appropriate concepts, principles, and theories. Give special attention to observed events that vary from the scholarly literature.
  • Determine how the problem, situation, or issue was handled in a manner that is consistent and a manner that is inconsistent with the theory, concepts, and principles detailed in the evidence.
  • Given the various evidence-based approaches that can be used in handling the observed problem, situation, or issue, think about a plan for approaching the matter differently.

To complete the Practicum and Journal Entry 2:

In your saved version of the NURS 6600 Practicum Journal document, do the following:

  • Write a 250- to 300-word journal entry (identified as Journal Entry 2) in which you do the following:
    • Describe a problem, issue, or situation that you have observed during your Practicum Experience (no more than a half page).
    • Using no fewer than three peer-reviewed sources of evidence, analyze what you have observed within the context of your specialty using appropriate concepts, principles, and theories. Give special attention to observed events that vary from scholarly literature.
    • Explain how the problem, situation, or issue was handled in a manner that is consistent and a manner that is inconsistent with the theory, concepts, and principles detailed in the evidence.
    • Given the various evidence-based approaches that can be used in handling the problem, situation, or issue, formulate a plan for approaching the matter differently.
    • Include references immediately following the content.
    • Use APA style for your journal entry and references.

 

Required Readings

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus

Matthews, J. H. (2012). Role of professional organizations in advocating for the nursing profession. Online Journal of Issues in Nursing, 17(1), 1.
Note: Retrieved from the Walden Library databases.

The author addresses the importance of involvement in professional organizations for nursing professionals.

Shekleton, M. E., Preston, J. C., & Good, L. E. (2010). Growing leaders in a professional membership organization. Journal of Nursing Management, 18(6), 662–668.
Note: Retrieved from the Walden Library databases.

“In order to grow leaders an organization must make a commitment to develop and maintain an infrastructure that supports leadership development activities” (Shekleton, Preston, & Good, 2010, p. 667). The authors discuss findings from a leadership development program.

American Association of Critical Care Nurses. (n.d.). Certification for nurse managers and leaders. Retrieved May 20, 2013, from http://www.aacn.org/wd/certifications/content/cnmlhome.pcms?menu=certification

The American Association of Critical Care Nurses Certification Corporation, in collaboration with the AONE credentialing center, offers certification for the nurse leader-manager.