| Course | NR 569 Differential Diagnosis in Acute Care Practicum |
|---|---|
| Week | 3 |
| Paper type | Differential narrowing memo |
| Length | About 950 words, 4 pages |
| Format | Memo with APA 7 citations |
| School | Chamberlain University |
| Program | MSN, Adult-Gerontology Acute Care NP (AGACNP) |
| Updated | October 2026 |
Free sample paper for NR 569 Week 3
Memorandum
To: Preceptor, Hospital Medicine Service
From: Acute care nurse practitioner student
Date: Hospital day 2, 10:00
Re: Narrowing the admission differential for the 47-year-old after gastric bypass
Purpose
This memo records how the eight-entry list from last night's admission write-up was narrowed this morning. It shows the full starting list, what removed each entry and how firm each removal is, and it names the three entries that remain and what still separates them. Firmness is graded on three levels: closed by a result, closed by a result that is still provisional, and set aside on history or reasoning alone.
The Starting List, in Full
The list written at 23:10 last night, in its original order but with each entry shortened to a label: (1) fluid loss with hypokalemia and hypomagnesemia; (2) hypoglycemia; (3) abdominal sepsis; (4) promethazine sedation; (5) vertebrobasilar stroke; (6) thiamine deficiency (Wernicke); (7) subclinical seizure activity; (8) liver failure with encephalopathy. All eight appear in the table below, including those that stay.
What Took Each Item Off
Table 1
The Admission List, With the Source and Firmness of Each Removal
| Entry | What took it off, or why it stays | Firmness |
|---|---|---|
| Volume depletion, low potassium and magnesium | Stays. Present, but cannot explain a gait that needs two staff in a 47-year-old with normal strength | Not removed |
| Low blood sugar | Glucose 142 after dextrose and above 100 on every check since; confusion unchanged 14 hours later | Firm: closed by repeated results over time |
| Intra-abdominal sepsis | CT at 01:40: no leak, no collection, narrowing at the gastric pouch outlet; lactate down to 2.9; cultures with no growth at 15 hours | Provisional: cultures not final |
| Promethazine effect | Last dose about 40 hours before my morning examination, with the drug's elimination half-life well under that; no anticholinergic signs | Soft: rests on the count from the box and the timing |
| Posterior circulation stroke | Stays. Nothing yet has separated it from entry 6 | Not removed |
| Wernicke encephalopathy | Stays | Not removed |
| Nonconvulsive seizures | No witnessed events overnight; attention poor but steady across three checks; EEG not yet available | Soft: set aside on observation alone |
| Hepatic encephalopathy | Liver enzymes, bilirubin and albumin pattern give no sign of liver disease | Firm on the liver; see the note below |
The low blood sugar removal is the firmest on the page. A low glucose can cause confusion, but correcting it should improve thinking within hours. Fourteen hours of normal readings with no change in orientation removes it as the cause, though it may have contributed.
The sepsis removal is provisional. The CT answered the question I most feared, a leak, and found something useful instead: a narrowing at the outlet of the gastric pouch, which explains three weeks of vomiting. Lactate fell with fluid but did not normalize. I am treating the cultures as the last word on this entry and will reopen it if they turn positive.
A Note on the Hepatic Entry
I removed hepatic encephalopathy on normal liver tests and graded the removal firm. I want to record a doubt about that grade. Normal liver tests rule out liver failure, but they say nothing about a raised ammonia from another cause, and I have not checked whether that can happen after a gastric bypass. I am leaving the removal in place for now and flagging it for the revised note.
The Three That Stay
1. Fluid loss with hypokalemia and hypomagnesemia. It is real and being corrected, but it is a companion rather than an explanation for the gait.
2. Posterior circulation stroke. Falls, inability to walk and vomiting fit a cerebellar or brainstem event. Its age does not remove it. I wrote last night that 47 is young for this kind of stroke, and on reflection that is a reason to rank it lower, not a reason to drop it.
3. Wernicke encephalopathy. The setting is strong: weeks of vomiting after a bypass, a stopped multivitamin and a glucose load given before thiamine. Its standing rose overnight because the entries above it fell away, not because anything new pointed to it.
What separates entries 2 and 3 is not yet on the page. Both can produce confusion, unsteady walking and vomiting. The diagnostic criteria proposed for thiamine deficiency require two of four features: a dietary deficiency, eye signs, cerebellar dysfunction and an altered mental state or mild memory problem (Caine et al., 1997). This patient already meets three of those four without any eye signs at all. A fuller eye examination is the obvious next step, and the European guideline advises that thiamine be given before any carbohydrate whenever this diagnosis is suspected (Galvin et al., 2010).
Requests
I ask for three things. First, a formal eye movement examination this afternoon, including gaze holding in each direction and abduction on each side. Second, a change in the thiamine order from the 100 mg in last night's infusion to the treatment regimen the guideline names, 200 mg by vein three times a day (Galvin et al., 2010), before the next dextrose-containing fluid. Third, an add-on whole blood thiamine level to the lavender-top tube drawn at triage, which was collected before any thiamine was given.
What This Memo Does Not Claim
It does not claim that the three entries are equally likely. It does not claim a diagnosis. Two removals rest on observation and reasoning rather than on results, and one firm removal now carries a doubt. Premature closure, settling on a diagnosis and stopping the search, was the most common cognitive contributor in a review of diagnostic errors in internal medicine (Graber et al., 2005), and the grades in the table exist to prevent this list from closing on the wrong item.
References
Caine, D., Halliday, G. M., Kril, J. J., & Harper, C. G. (1997). Operational criteria for the classification of chronic alcoholics: Identification of Wernicke's encephalopathy. Journal of Neurology, Neurosurgery & Psychiatry, 62(1), 51-60. https://doi.org/10.1136/jnnp.62.1.51
Galvin, R., Brathen, G., Ivashynka, A., Hillbom, M., Tanasescu, R., & Leone, M. A. (2010). EFNS guidelines for diagnosis, therapy and prevention of Wernicke encephalopathy. European Journal of Neurology, 17(12), 1408-1418. https://doi.org/10.1111/j.1468-1331.2010.03153.x
Graber, M. L., Franklin, N., & Gordon, R. (2005). Diagnostic error in internal medicine. Archives of Internal Medicine, 165(13), 1493-1499. https://doi.org/10.1001/archinte.165.13.1493
The Chamberlain NR 569 Week 3 instructions
The Week 3 memo usually asks you to take the list from your write-up and shorten it, showing your work. Expect one to three pages in memo format, addressed to the person your section names, often a preceptor. The full starting list should appear, not only what survives. For every entry that comes off, the memo states what removed it and how firm that removal is, since a removal based on a result is stronger than one based on a history detail. Two or three entries should remain, with a line on what still separates them. Some sections want the narrowing in a table; others accept a numbered run. Requests for the next step often close the memo.
Inside the NR 569 Week 3 example
The sample uses the memo header, a one-paragraph purpose statement and the starting list in its original order with shortened labels. A table carries all eight entries, the reason each came off or stayed, and a firmness grade on three levels. The low glucose removal is called the firmest because it rests on repeated results over time; the sepsis removal is provisional because cultures are not final; promethazine and seizures are marked soft. A separate paragraph questions whether normal liver tests really close the hepatic entry. The three survivors are then described with what separates the two neurologic ones, citing the criteria for thiamine deficiency. Three dated requests and a short statement of what the memo does not claim follow.
NR 569 Week 3 rubric: what full points look like
Markers usually begin with the removals. A removal with nothing next to it is the costliest gap, because it cannot be told apart from an oversight. Removing an item because it is uncommon also loses marks, since that reasoning would have thinned the list before the patient arrived. The firmness row wants removals graded differently, and this memo uses three levels with reasons. Points for the starting list depend on showing all of it. The surviving pair earns credit when the memo names what still separates them, here an eye examination and imaging. Professional memo format and specific, timed requests typically fill the communication row in sections that grade it.
NR 569 Week 3 help from the desk
The usual NR 569 Week 3 problem is a memo that shows only the short list and none of the removals, which hides the reasoning the week grades. Another is grading every removal as certain when some rest only on history. Writers also drop a close pair without explanation, or remove a serious condition because the patient seems too young, a reason this sample flags as weak. Memos that run as essays, with no table or numbering, are hard to mark. If your section uses a template, send it with your write-up list; a memo for your patient can be drafted the same way, keeping every entry on the page with its source and grade.
Get a NR 569 Week 3 example written to your instructions
Forward the Week 3 instructions with any memo template your section posts, and say who the memo is addressed to, since the header changes what the opening lines carry. A custom example written to those comes back inside 24 to 48 hours, the first one free. If the starting list is given to you, include it and the removals are worked from that list.
More NR 569 papers and AGACNP samples
- NR 569 Week 1: Fever and Back Pain Discussion Post
- NR 569 Week 2: Undifferentiated Presentation Write-Up
- NR 569 Week 4: Discriminating Feature Brief
- NR 569 Week 5: Diagnostic Test Rationale
- NR 569 Week 6: Reasoning Journal Entry
- NR 569 Week 7: Revised Differential Note
- NR 569 Week 8: Diagnostic Accuracy Review
- NR 567 Week 3: Nicardipine Titration Plan
NR 569 Week 3 questions, answered
How many items should be left at the end?
Fewer than people expect, and what counts more is whether each survivor still has something arguing for it. Two or three is common and one is acceptable when the removals earned it. A memo ending with six has usually recorded a reordering rather than a narrowing, and sections marking this row read it that way.
Can a removal be reversed later in the term?
Yes, and Week 7 is generally where that happens. A removal is a claim about the information in hand when it was made, so one that turns out wrong is not automatically a mark lost. What costs is a memo written so firmly that nothing could reopen it. Grade the firmness honestly here and the later revision has something to work against.
Ours wants the memo as a table. Does that change the reasoning?
No, and a table often helps, because the three columns a narrowing memo needs are the item, what took it off and how firm that is. What a table makes harder is the unsettled pair, which needs a sentence rather than a cell. Where a table is required, the sample arrives as one with that paragraph written underneath.
Where can I find a free NR 569 Week 3 sample paper?
On this page: the full narrowing memo for the patient after gastric bypass, with all eight starting entries, a firmness grade for each removal and the three requests to the preceptor.
What does firmness mean in the NR 569 Week 3 narrowing memo?
It is how solid a removal is. Here an entry closed by repeated results is firm, one awaiting final cultures is provisional, and one set aside on history or observation alone is soft.