Diagnostic Reasoning Clinical decision making is the process by which we determine who needs what and when. While not exactly arbitrary, this exercise can be quite subjective. Eac
Topic: Diagnostic Reasoning
Clinical decision making is the process by which we determine who needs what and when. While not exactly arbitrary, this exercise can be quite subjective. Each provider compiles their own data (hence the emphasis on learning to perform an accurate H&P) and then constructs an argument for a particular disease state based on their interpretation of the "facts." The strength of their case will depend on the way in which they gather and assemble information. There may then be no single, right way of applying diagnostic and therapeutic strategies to a particular case. Medicine involves playing the odds, assessing the relative chance that a patient is/is not suffering from a particular illness. Codifying the way in which providers logically approach problems and deal with this uncertainty is a difficult task. Relying solely on the classic features of a disease may be misleading. That is 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 two 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.
Discussion 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 a serious diagnosis 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 a sufficient understanding of the clinical presentation to offer an opinion on the diagnosis?
- What other diagnoses could it be? How might the treatment to date have altered the patient's 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?
- Please support with up-to-date evidence-based standard of care guidelines that are less than 5 years old.
- GuidelinesContains unread postsLaura Shenkman posted Jul 24, 2022 9:32 AM
SubscribeClass, Are you familiar with the current clinical practice guidelines (2019-2022) and the investigation of a suspected condition such as chest pain? Where would you look for these guidelines? Professor Shenkmanless0 Unread0Unread0 Replies0Replies0 Views0Views
Rubric Title:
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MSN 25 point Discussion Rubric |
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Criteria 1 |
Level III Max Points Points: 5 |
Level II Max Points Points: 4 |
Level I Max Points Points: 3 |
Not Present 0 Points |
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Identification (20%) |
· Thorough identification of the importance of the subject matter to the individual, clinical, and professional. · Supports discussion concepts through personal experience and evidence-based information. · Submits a minimum of three posts, one initial and two responses to either the course faculty or peers, with thorough reflection and content. |
· Reflection of subject to self, clinical, and professional importance with minimal integration of evidence-based information. · Submits two or more posts with some reflection and content. |
· Minimal reflection without reference to personal, clinical, or profession. · Submits one or more posts that have minimal reflection or content. |
No Posts |
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Criteria 2 |
Level III Max Points Points: 15 |
Level II Max Points Points: 12 |
Level I Max Points Points: 9 |
Not Present 0 Points |
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Reflection/Participation/Knowledge (60%) |
· Provides a well-written reflection that is clearly connected to the outcomes and clinical insight. · Responds to at least two other student postings with a response that advances the discussion. · Clear critical thinking acknowledges application, analysis, synthesis, and evaluation. · Replies move the conversation forward. Makes a reply to a question asked in response to their own posting. · Builds a focused argument. · Asks new or related questions. · Makes an oppositional or congruent statement that is supported by experience or research. |
· Provides a well-written reflection and there is a clear connection to outcomes, but lacks clinical insight. · Replies partially move the conversation forward. Makes a reply to question asked in response to their own posting. · Some clear critical thinking acknowledges application, analysis, synthesis, and evaluation. · Affirms statements or references to relevant research. · Asks similar or related questions within the context of the conversation. |
· Provides short reflection and there is a slight connection to outcomes. · Student does not move the conversation forward within their own post or in their response to peer/faculty. · Minimal critical thinking that acknowledges application, analysis, synthesis, and evaluation. · Does not affirm or oppose statements in conversation. · Does not pose or ask related question in the context of DB conversation. |
No Posts |
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Criteria 3 |
Level III Max Points Points: 5 |
Level II Max Points Points: 4 |
Level I Max Points Points: 3 |
Not Present 0 Points |
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Format/Style/APA/ Citations (20%) |
· No grammar, word usage, or punctuation errors. Overall style is consistent with professional work. · Writing style facilitates communication. · Provides three references that are relevant to the content and published within the last five years. |
· Fewer than three grammatical errors. · Provides less than three references that are relevant to the content and published within the last five years. · Writing style facilitates some communication. |
· More than three grammatical errors. · Provides less than three references that are relevant to the content and published within the last five years. · Writing style does not facilitate communication. |
No Posts |
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Maximum Total Points |
25 |
20 |
15 |
0 |
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Minimum Total Points |
21 points minimum |
16 points minimum |
1 point minimum |
0 |
Rubric Title: Unit 2, 4, 6 Lab – Virtual Reality Rubric
***Students: It is IMPORTANT to remember to utilize both the “Guided Mode” and “Expert Mode” in the VR Lab Simulation case scenario experiences, as you practice the VR Lab scenario(s). The “Guided Mode” and “Expert Mode” allow you to have multiple tries/attempts to practice the case. THEN, when you feel you are ready, you will choose the VR Lab “Exam Mode” (that you can ONLY attempt once); the score you receive in “Exam Mode” will then be your final grade in the VR Lab. If you have any questions regarding this, please follow up with your course instructor.
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Level III |
Level II |
Level I |
Not Present |
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Criteria 1 |
Level III Points: 80 |
Level II Points: 64 |
Level I Points: 48 |
Not Present 0 Points |
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Total Score |
· Within Exam Mode, obtains 65 to 80 points of the required total components for virtual reality patient scenario |
· Within Exam Mode, obtains between 49 to 64.9 points of the required total components for virtual reality patient scenario |
· Within Exam Mode, obtains between 33 to 48.9 points of the required total components for virtual reality patient scenario |
· Does not attempt in Exam Mode · Does not meet the criteria |
Rubric Title: Unit 3, 5, 7 SOAP Journal Assignment Rubric
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Criteria 1 |
Level III Max Points Points: 8 |
Level II Max Points Points: 6.4 |
Level I Max Points Points: 4.8 |
0 Points |
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Content Quality- Subjective Data |
Subjective data displays complete understanding of all critical concepts of virtual reality patient case including: · Name, age, gender · Chief complaint · History of present illness (HPI) that follows OLD CARTS pneumonic · Medications · Allergies · Past medical history · Past surgical history · Pertinent family history · Social history · Review of Systems |
· Subjective data displays understanding of critical concepts of chosen virtual reality patient case; there may be 1-2 critical concepts with errors/omissions or lack of details. |
· Subjective data displays understanding of critical concepts of chosen virtual reality patient case; there may be 3-4 critical concepts with errors/omissions or lack of details. |
· Does not meet criteria |
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Criteria 2 |
Level III Max Points Points: 8 |
Level II Max Points Points: 6.4 |
Level I Max Points Points: 4.8 |
Not Present 0 Points |
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Content Quality- Objective Data |
Objective data displays complete understanding of all critical concepts of chosen virtual reality patient case including: · Vital signs · Body systems that are pertinent to specific case |
· Objective data displays understanding of critical concepts of chosen virtual reality patient case; there may be 1-2 critical concepts with errors/omissions or lack of details. |
· Objective data displays understanding of critical concepts of chosen virtual reality patient case; there may be 3-4 critical concepts with errors/omissions or lack of details |
· Does not meet criteria |
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Criteria 3 |
Level III Max Points Points: 4 |
Level II Max Points Points: 3.2 |
Level I Max Points Points: 2.4 |
Not Present 0 Points |
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Content Quality- Assessment |
Assessment displays complete understanding of all critical concepts of chosen virtual reality patient case including: · Primary diagnosis · Pathophysiology of primary diagnosis · Three differential diagnoses · Rationales for differential diagnoses |
· Assessment displays understanding of critical concepts of chosen virtual reality patient case; there may be 1 critical concept with errors/omissions or lack of details. |
· Assessment displays understanding of critical concepts of chosen virtual reality patient case; there may be 2 critical concepts with errors/omissions or lack of details. |
· Does not meet criteria |
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Criteria 4 |
Level III Max Points Points: 4 |
Level II Max Points Points: 3.2 |
Level I Max Points Points: 2.4 |
Not Present 0 Points |
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Content Quality- Plan of Care |
Plan displays complete understanding of all critical concepts of chosen virtual reality patient case including: · Medications · Non-pharmacological recommendations · Diagnostic tests · Patient education · Cultural considerations · Health promotion · Referrals · Follow-Up |
· Plan displays understanding of critical concepts of chosen virtual reality patient case; there may be 1 critical concept with errors/omissions or lack of details. |
· Plan displays understanding of critical concepts of chosen virtual reality patient case; there may be 3-4 critical concepts with errors/omissions or lack of details. |
· Does not meet criteria |
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Criteria 5 |
Level III Max Points Points: 3 |
Level II Max Points Points: 2.4 |
Level I Max Points Points: 1.8 |
Not Present 0 Points |
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Collegiate-level academic writing |
· Includes no more than three grammatical, spelling, or punctuation errors that do not interfere with the readability. · Supports all opinions and ideas with relevant and credible reference sources of information. · Provides three or more peer-reviewed or evidence-based practice scholarly references sources. · All reference sources are within the past five years. |
· Includes no more than four grammatical, spelling, or punctuation errors that do not interfere with the readability. · Supports many opinions and ideas with relevant and credible sources of information. · Provides two peer-reviewed or evidence-based practice scholarly references sources. · All reference sources are within the past five years. |
· Includes five or more grammatical, spelling, and punctuation errors that makes understanding parts of assignment difficult, but does not interfere with readability. · Not all references utilized are relevant and/or credible sources of information. · Provides one peer-reviewed or evidence-based practice scholarly references source. · Reference sources are within the past five years. |
· Does not meet criteria |
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Criteria 6 |
Level III Max Points Points: 3 |
Level II Max Points Points: 2.4 |
Level I Max Points Points: 1.8 |
0 Points |
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Citations and Formatting |
● The overall order of information is clear and contributes to the meaning of the assignment. There may be 1-2 sentences, or one paragraph that is out of order, or other minor organization issues. ● Correctly citing all reference sources. One or two formatting, in-text, or reference citation errors may occur. ● Quotation marks and citations make authorship clear. |
● The overall order of information is confusing in places due to 3-4 sentences, or two paragraphs that may be out of order, or other organization issues that interfere with the meaning or intent of the paper. ● Correctly citing all reference sources. 3-4 formatting, in-text, or reference citation errors may occur. ● Quotation marks and citations generally, make authorship clear. |
● The overall order of information is confusing in places due to 5-6 sentences or three paragraphs that may be out of place, or other organization issues that interfere with the meaning or intent of the paper. ● Attempts to cite. 5-6 formatting, in-text, or reference citation errors may occur. ● Quotation marks and citations may be missing or incorrect. ● Authorship may be unclear in areas. |
· Does not meet criteria |
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Maximum Total Points |
30 |
24 |
18 |
|
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Minimum Total Points |
25 |
19 |
Rubric Title: Unit 8 Journal Rubric
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Level III Max Points Points: 15 |
Level II Max Points Points: 12 |
Level I Max Points Points:9 |
0 Points |
|
|
Content Quality- Subjective Data |
Presentation of subjective data displays complete understanding of all critical concepts of chosen virtual reality patient case including: · Name, age, gender · Chief complaint · History of present illness (HPI) that follows OLD CARTS pneumonic · Medications · Allergies · Past medical history · Past surgical history · Pertinent family history · Social history · Review of Systems |
· Presentation of subjective data displays understanding of all critical concepts of chosen virtual reality patient case; there may be 1-2 critical concepts with errors/omissions or lack of details. |
· Presentation of subjective data displays understanding of all critical concepts of chosen virtual reality patient case; there may be 3-4 critical concepts with errors/omissions or lack of details. |
· Does not meet the criteria |
|
Criteria 2 |
Level III Max Points Points: 15 |
Level II Max Points Points: 12 |
Level I Max Points Points:9 |
0 Points |
|
Content Quality- Objective Data |
Presentation of objective data displays complete understanding of all critical concepts of chosen virtual reality patient case including: · Vital signs · Body systems that are pertinent to specific case |
· Presentation of objective data displays understanding of all critical concepts of chosen virtual reality patient case; there may be 1-2 critical concepts with errors/omissions or lack of details. |
· Presentation of objective data displays understanding of all critical concepts of chosen virtual reality patient case; there may be 3-4 critical concepts with errors/omissions or lack of details. |
· Does not meet the criteria |
|
Criteria 3 |
Level III Max Points Points: 15 |
Level II Max Points Points: 12 |
Level I Max Points Points:9 |
0 Points |
|
Content Quality- Assessment |
Presentation of assessment displays complete understanding of all critical concepts of chosen virtual reality patient case including: · Primary diagnosis · Pathophysiology of primary diagnosis · Three differential diagnoses · Rationales for differential diagnoses |
· Presentation of assessment displays understanding of all critical concepts of chosen virtual reality patient case; there may be one critical concept with errors/omissions or lack of details. |
· Presentation of assessment displays understanding of all critical concepts of chosen virtual reality patient case; there may be two critical concepts with errors/omissions or lack of details. |
· Does not meet the criteria |
|
Criteria 4 |
Level III Max Points Points: 15 |
Level II Max Points Points: 12 |
Level I Max Points Points:9 |
0 Points |
|
Content Quality- Plan of Care |
Presentation of plan displays complete understanding of all critical concepts of chosen virtual reality patient case including: · Medications · Non-pharmacological management · Diagnostic tests · Patient education · Cultural considerations · Health promotion · Referrals · Follow-Up |
· Presentation of plan displays understanding of all critical concepts of chosen virtual reality patient case; there may be one critical concept with errors/omissions or lack of details. |
· Presentation of plan displays understanding of all critical concepts of chosen virtual reality patient case; there may be 3-4 critical concepts with errors/omissions or lack of details.s |
· Does not meet the criteria |
|
Criteria 5 |
Level III Max Points Points: 15 |
Level II Max Points Points: 12 |
Level I Max Points Points:9 |
0 Points |
|
Quality of Oral Presentation |
· Presentation demonstrated thorough organization and delivery. · All ideas were stated in a clear and logical manner. · Presentation was on topic and relevant. · Presentation time no longer than 5 minutes |
· Presentation was organized and well spoken. · All ideas were stated in a clear and logical manner. · Presentation was on topic and relevant. · Presentation >5 minutes |
· Presentation needed more details or content inconclusive. · Presentation >5 minutes |
· Does not meet the criteria |
|
Maximum Total Points |
75 |
60 |
45 |
0 |
|
Minimum Total Points |
61 |
46 |
1 |
,
Textbook Reading
Primary Care: The art and Science of Advanced Practice Nursing
· Chapter 2: Caring and the Advanced Practice Nurse
· Chapter 3: Health Promotion
· Chapter 4: The Art of Diagnosis and Treatment
· Chapter 5: Evidence Based Practice
Resources
PowerPoint Links:
· American Cancer Society. (2021). Cancer Screening Guidelines. https://www.cancer.org/healthy/find-cancer-early/cancer-screening-guidelines.html
· Centers for Disease Control. (2021). Immunization schedules. https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html
· Center for Disease Control. (2021) Recommended Adult Immunization Schedules https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf
· U.S. Preventive Services Task Force. (2021). USPSTF A and B screening recommendations. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
· Department of Health and Human Services, Office of Disease Prevention and Health Promotion (ODPHP). (2021). Healthy People 2030 https://health.gov/healthypeople
· U.S. Preventive Services Task Force. (2021). USPSTF all screening recommendations. https://www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations
Unit 2 Reading:
Textbook Reading
Primary Care: The art and Science of Advanced Practice Nursing
· Chapter 34: Cardiovascular Problems
· Chapter 35: Cardiac and Associated Risk Disorders
· Chapter 36 Dysrhythmias and Valvular Disorders
· Chapter 37: Disorders of the Vascular System
Resources
· https://www.ahajournals.org/doi/epub/10.1161/HYPERTENSIONAHA.120.15026
· Department of Health and Human Services, Office of Disease Prevention and Health Promotion (ODPHP). (2021). Healthy People 2030. https://health.gov/healthypeople/objectives-and-data/browse-objectives/heart-disease-and-stroke
· The JNC 8 Hypertension Guidelines: An In-Depth Guide ( 2014),
· https://www.ajmc.com/view/the-jnc-8-hypertension-guidelines-an-in-depth-guide
Unit 2 Assignment:
VR Angela Atwater Hypertension Stage 2, and overweight
Unit 3 Reading:
Textbook Reading
Primary Care: The art and Science of Advanced Practice Nursing
· Chapter 28: Common Respiratory Complaints
· Chapter 29 Sleep Apnea
· Chapter 30: Infectious Respiratory Disorders
· Chapter 31: Inflammatory Respiratory Disorders
· Chapter 32: Lung Cancer
· Chapter 33: Smoking Cessation
Resources
· _sites_default_files_publications_AsthmaManagementGuidelinesReport-2-4-21.pdf
· Center for Disease Control and Prevention, (2021) Asthma Action Plans https://www.cdc.gov/asthma/actionplan.html
· Soap Note Template SOAP NOTE TEMPLATE (3).docx
Unit 4 Reading:
Textbook Reading
Primary Care: The art and Science of Advanced Practice Nursing
· Chapter 56: Common Endocrine and Metabolic Complaints
· Chapter 57: Glandular Disorders
· Chapter 58: Diabetes Mellitus
· Chapter 59: Metabolic Disorders
Resources
American Diabetes Association. (2021) Practice Guideline Resources.
https://professional.diabetes.org/content-page/practice-guidelines-resources
Center For Disease Control, (2021). Gout.https://www.cdc.gov/arthritis/basics/gout.html
Egan,B.,(2021),Treatment of Hypertension in Black Individuals. UpToDate.
https://www.uptodate.com/contents/treatment-of-hypertension-in-black-individuals
Fitzgerald,J.d, etal.American College of Rheumatology Guidelines; 2020 American College of Rheumatology Guideline for the Management of Gout Arthritis Care & Research Vol. 0, No. 0, June 2020, pp 1–17 DOI 10.1002/acr.24180 © 2020. https://www.rheumatology.org/Portals/0/Files/Gout-Guideline-Early-View-2020.pdf
Mayo Clinic, (2021) Gout. https://www.mayoclinic.org/diseases-conditions/gout/symptoms- causes/syc-20372897
Unit 4 Assignment:
For this Activity, go to VR /James Hanson/Gout
Unit 5 Reading:
Textbook Reading
Primary Care: The art and Science of Advanced Practice Nursing
· Chapter 6: Common Neurological Complaints
· Chapter 7: Seizure Disorders
· Chapter 8: Degenerative Disorders
· Chapter 9 Stroke
· Chapter 10: Infectious and Inflammatory Neurological Disorders
Resources
· Soap Note Template SOAP NOTE TEMPLATE (3).docx
Unit 6 Reading:
Textbook Reading
Primary Care: The art and Science of Advanced Practice Nursing
· Chapter 52: Common Musculoskeletal Complaints
· Chapter 53: Spinal Disorders
· Chapter 54: Soft Tissue Disorders
· Chapter 55.: Osteoarthritis and Musculoskeletal Problems
Unit 7 Reading:
Textbook Reading
Primary Care: The art and Science of Advanced Practice Nursing
· Chapter 43: Common Urinary Complaints
· Chapter 44: Urinary Tract Disorders
· Chapter 45: Kidney and Bladder Disorders
Resource
Center For Disease Control and Prevention (CDC),2021 Acute Low Back Pain
https://www.cdc.gov/acute-pain/low-back-pain/index.html
SOAP Note Template SOAP NOTE TEMPLATE (3).docx
Unit 8 Reading:
Textbook Reading
Primary Care: The art and Science of Advanced Practice Nursing
· Chapter 18: Common Eye Complaints
· Chapter 19: Lid and Conjunctival Pathology
· Chapter 20: Visual Disturbances and Impaired Vision
· Chapter 21: Common Ear, Nose and Throat Complaints
· Chapter 22: Hearing and Balance Disorders
· Chapter 23: Inflammatory and Infectious Disorders of the Ear
· Chapter 24: Inflammatory and Infectious Disorders of the Nose, Sinuses and Throat
· Chapter 25: Epistaxis
Unit 9 Reading:
Textbook Reading
Primary Care: The art and Science of Advanced Practice Nursing
· Chapter 79: Ethical and Legal Issues of a Caring Based Practice
· Chapter 38: Common Abdominal Complaints
· Chapter 39: Infectious Gastrointestinal Disorders
· Chapter 40: Gastric Disorders
· Chapter 41: Gall Bladder and Pancreatic Disorders
· Chapter 42: Cirrhosis and Liver Failure
Unit 10 Reading:
Textbook Reading
Primary Care: The art and Science of Advanced Practice Nursing
· Chapter 64: Common Psychosocial Complaints
· Chapter 65: Substance Use Disorder
· Chapter 66: Schizophrenic Spectrum Disorders
· Chapter 67: Mood Disorders
· Chapter 68: Anxiety, Stress and Trauma-Related Disorders
· Chapte
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