| Course | NR 569 Differential Diagnosis in Acute Care Practicum |
|---|---|
| Week | 2 |
| Paper type | Undifferentiated presentation write-up |
| Length | About 1,160 words, 5 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | MSN, Adult-Gerontology Acute Care NP (AGACNP) |
| Updated | October 2026 |
Free sample paper for NR 569 Week 2
Confusion, Two Falls and Three Weeks of Vomiting Nine Weeks After Gastric Bypass: An Undifferentiated Presentation Write-Up From the Night of Admission
Student Name
College of Nursing, Chamberlain University
NR 569: Differential Diagnosis in Acute Care Practicum
Instructor Name
Month Day, Year
Confusion, Two Falls and Three Weeks of Vomiting Nine Weeks After Gastric Bypass: An Undifferentiated Presentation Write-Up From the Night of Admission
The Complaint, in the Words Used at the Bedside
The patient, a composite drawn from the hospital medicine service where I am placed this term, is 47 years old and was brought to the emergency department at 18:20 by an older sibling who shares the house. The sibling's words were these: "Foggy since Sunday, and fell twice in the kitchen." The patient's own words, asked what was wrong, were: "My legs won't go where I tell them." I record both because they point in slightly different directions. The sibling describes thinking; the patient describes walking.
The History, Running Forward
Nine weeks ago the patient underwent a Roux-en-Y gastric bypass, done laparoscopically at another hospital, after years of obesity, hypertension and sleep apnea. The first five weeks went to plan, with a weight loss of about 22 kg. Around week six the patient began vomiting after most solid meals and, within days, after liquids as well. The sibling estimates that only sips of broth and sports drink have stayed down for the last 21 days. The chewable multivitamin the surgical team prescribed was stopped about four weeks ago because it caused gagging. An urgent care clinic prescribed promethazine suppositories ten days ago; the sibling brought the box, and four of twelve remain.
On Sunday, four days before admission, the sibling noticed the patient repeating questions and losing track of a television program. On Tuesday the patient fell while turning from the counter, and fell again this morning. There was no head strike that anyone saw, no shaking and no loss of bladder control. The patient does not drink alcohol; the sibling confirms none in the house for years. Home medicines are omeprazole 40 mg daily and ursodiol 300 mg twice daily, both from the surgical team. The opioid prescribed after surgery was finished in week two.
Examination, Written as Findings
At triage: temperature 37.1 C, pulse 112, pressure 98/62, 18 breaths a minute, saturation 97% breathing room air, and a fingerstick glucose of 61 mg/dL. The emergency team gave 25 g of dextrose by vein at 18:50 and a multivitamin infusion containing 100 mg of thiamine at 20:30.
On my examination at 22:40, the patient was awake, oriented to name only, and could not give the month. Attention was poor: the patient could not list the days of the week backward past Friday. Mucous membranes were dry. The abdomen was soft, with healed port sites and mild epigastric tenderness, no guarding and no distension. Speech was clear. Strength was 5 of 5 in all four limbs. Pupils were equal and reactive, and extraocular movements were full to casual tracking. Standing required two staff; the base was wide, and the patient could not take a step without reaching for the bed rail.
Looked for and not found: no neck stiffness; no asterixis; no tongue bite; no rash; no focal weakness; no facial droop; no incontinence; no jaundice. Each absent finding is recorded because each was a question asked of a specific entry below.
Results Available at the Time of Writing
Sodium 132 mmol/L, potassium 3.0, chloride 92, bicarbonate 20, so an anion gap of 20. Magnesium 1.3 mg/dL. Urea nitrogen 24 and creatinine 1.1, so the kidneys are holding up. Lactate 3.6 mmol/L. White count 9.8, hemoglobin 12.1. Liver enzymes, bilirubin and lipase within range. Ethanol undetectable; urine drug screen negative. Urine: specific gravity 1.030, ketones 3+, no nitrites. Noncontrast head CT: no acute finding. CT of the abdomen with contrast was ordered at 21:15 and has not been read. Blood cultures are drawn.
The List, Barely Ordered
This is the list as it stands at 23:10 on the night of admission. The order is loose; the attachments are not.
1. Volume depletion with low potassium and magnesium from prolonged vomiting. Attached to: 21 days of vomiting, heart rate 112, pressure 98/62, specific gravity 1.030, potassium 3.0, magnesium 1.3.
2. Encephalopathy from low blood sugar. Attached to: triage glucose 61 after weeks of minimal intake.
3. Sepsis from an intra-abdominal source such as a leak or collection. Attached to: tachycardia, lactate 3.6, surgery nine weeks ago, epigastric tenderness. The CT is pending.
4. Sedating drug effect from promethazine. Attached to: eight suppositories used in ten days, per the box.
5. Stroke in the posterior circulation. Attached to: falls, inability to walk without support, vomiting.
6. Wernicke encephalopathy from thiamine deficiency. Attached to: bariatric surgery, three weeks of vomiting, the stopped multivitamin, confusion and the unsteady gait. Ranked low: no alcohol use, and extraocular movements were full to casual tracking.
7. Nonconvulsive seizures. Attached to: fluctuating attention.
8. Hepatic encephalopathy. Attached to: confusion after abdominal surgery; normal liver tests weigh against it.
The Account and Its Source
Most of the history came from the sibling. The patient answered simple questions but could not date events, so the timeline of vomiting and confusion is the sibling's. The surgical details came from the discharge summary faxed from the operating hospital at 21:00. The suppository count is from the box. Where the two household accounts disagree, I have kept both: the sibling saw a thinking problem first, while the patient feels a walking problem.
The reliability of each source differs. The sibling has lived with the patient for six years and noticed the change in thinking before anyone else, but did not see either fall directly; the second was heard from the next room. The discharge summary is precise about the operation and silent about nutrition teaching. The patient's own account is limited by the confusion it is meant to describe, so I have used it for symptoms the patient feels, such as the legs not obeying, and not for dates.
Nothing Is Settled
I have not placed a name on this presentation. Several entries can coexist, and the first entry would explain the heart rate without explaining why someone who is 47 cannot walk across a room. The CT result, a repeat glucose after the dextrose wears off and a fuller neurologic examination tomorrow morning are the next pieces of information I expect to change the list.
Background Read After Writing
Aasheim (2008) reviewed 84 published cases of thiamine deficiency encephalopathy after bariatric surgery, and in nine of every ten of them the patient had been vomiting often. Singh and Kumar (2007) found cases from two weeks to 18 months after surgery. Harper et al. (1986) reported that only 16% of necropsy-proven cases showed the classic triad during life. These figures were read after the list was written and did not change its order tonight.
References
Aasheim, E. T. (2008). Wernicke encephalopathy after bariatric surgery: A systematic review. Annals of Surgery, 248(5), 714-720. https://doi.org/10.1097/SLA.0b013e3181884308
Harper, C. G., Giles, M., & Finlay-Jones, R. (1986). Clinical signs in the Wernicke-Korsakoff complex: A retrospective analysis of 131 cases diagnosed at necropsy. Journal of Neurology, Neurosurgery & Psychiatry, 49(4), 341-345. https://doi.org/10.1136/jnnp.49.4.341
Singh, S., & Kumar, A. (2007). Wernicke encephalopathy after obesity surgery: A systematic review. Neurology, 68(11), 807-811. https://doi.org/10.1212/01.wnl.0000256812.29648.86
NR 569 Week 2 instructions, in plain terms
The Week 2 write-up asks you to present a patient whose problem has not yet been named, usually from your own rotation and sometimes from a case your section supplies. Expect two to four pages under the headings your section posts. The complaint should open the paper in the words actually used, followed by a history that runs forward in time. Examination findings are written as findings, and the things you looked for and did not find belong beside them. A loosely ordered list comes next, with each entry tied to a specific line in the history, examination or results. Many prompts also want a note on where the history came from and a closing statement of what remains unknown.
Inside the NR 569 Week 2 example
This example opens with two quoted complaints, one from the sibling about thinking and one from the patient about walking. The history moves from a Roux-en-Y bypass through weeks of vomiting to a stopped multivitamin, a promethazine box and two falls. Triage numbers, the dextrose given before thiamine and the evening examination follow, with eight absent findings listed. A results section gives the electrolytes, lactate and imaging. The eight-entry list attaches each condition to its source line, and thiamine deficiency is ranked sixth with two stated reasons. A section on sources weighs the sibling, the faxed summary and the patient. The last section names the results expected to change the list next.
Where the points sit in the NR 569 Week 2 rubric
Most of the points in this write-up sit with the list and the lines it is attached to. An entry that arrives with no source above it costs credit, because the reader cannot tell reasoning from habit. The examination row rewards findings sought and not found, so the sample records eight absent findings and says each answered a question about a specific entry. Quoting the complaint in the words used earns the opening marks. A history in time order, with the source named, satisfies the account row. The final row usually rewards restraint: a write-up that crowns one diagnosis on the first night reads like a finished case with the name removed, which this sample avoids.
NR 569 Week 2 help from the desk
In NR 569 Week 2, the paper that loses the most is written backward from the answer: a history arranged so only one explanation can follow, with the other entries trailing as decoration. Another frequent problem is a list with no attachments, which leaves the marker guessing why each item is there. Examinations that record only normal findings, with nothing sought, lose the examination row. Repeating one entry in different words counts once. Ordering tests before the list is complete also costs marks. If your rotation case differs, send the history and findings you have, and a write-up in this form can be built around your patient with every entry tied to its line.
Get a NR 569 Week 2 example written to your instructions
Attach the Week 2 instructions, the rubric rows and any write-up template your classroom posts, and a custom example written to them arrives inside 24 to 48 hours, the first one free. The arrival in it is invented. Your hours, your log and any form the unit countersigns stay on your side of this, and no sample is written to stand in for them.
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NR 569 Week 2 questions, answered
Our template has a section for the physical examination. What belongs in it?
The findings that moved an item up or down, plus the ones you looked for because an item was on your mind and did not find. A system by system sweep reproduced in full buries both. Where your template fixes the headings, the sample fills them, and anything the section marks as required stays in even when it turned out to be unremarkable.
Is a write-up with no working diagnosis going to lose points?
Not in most sections, and in Week 2 that is usually the point. The rubric rows here reward breadth held open with reasons attached, not a name arrived at early. What does cost is a list of eight with nothing separating any of them, which is breadth without work. Send the rubric and the desk writes to whichever balance your rows describe.
Our section supplies the case rather than asking for one from the rotation. Does the shape change?
Very little. A supplied case arrives already written, so the history section becomes selection rather than recall and the marks move further toward the list and its reason lines. What stays identical is the requirement that every entry point back at a line in the case by name. Include the case alongside the instructions and the desk works from it.
Where can I find a free NR 569 Week 2 sample paper?
This page shows the full write-up of the confused, unsteady patient after gastric bypass, with eight entries each tied to a source line. It can guide the layout of your own rotation case.
Why is Wernicke encephalopathy ranked sixth in this NR 569 Week 2 write-up?
The writer ranked it low for no alcohol use and for eyes that seemed normal on tracking. Both reasons are written down, which lets the later weeks examine them.