| Course | NR 569 Differential Diagnosis in Acute Care Practicum |
|---|---|
| Week | 7 |
| Paper type | Revised differential note |
| Length | About 1,150 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 7
Revised Differential Note on Hospital Day 4: The Admission List Unaltered, the Revision Beneath It and What Moved Each Item, Including One Put Back
Student Name
College of Nursing, Chamberlain University
NR 569: Differential Diagnosis in Acute Care Practicum
Instructor Name
Month Day, Year
Revised Differential Note on Hospital Day 4: The Admission List Unaltered, the Revision Beneath It and What Moved Each Item, Including One Put Back
The Original List, Unaltered
Written at 23:10 on hospital day 1. The order and the content are exactly as submitted; only the wording of each entry is shortened to a label so the two versions fit side by side, and nothing has been reordered or improved:
1. Fluid and electrolyte loss (potassium, magnesium) from vomiting.
2. Hypoglycemic encephalopathy.
3. Abdominal sepsis (leak, collection), CT pending.
4. Promethazine sedation.
5. Posterior stroke.
6. Wernicke, ranked low with two stated reasons: no drinking, and eyes judged normal on tracking.
7. Seizures without convulsions.
8. Liver-related encephalopathy.
The Revised List
Written at 11:00 on hospital day 4:
A. Wernicke encephalopathy from thiamine deficiency, after prolonged vomiting following Roux-en-Y gastric bypass.
B. Volume depletion with low potassium and magnesium, improving.
C. Narrowing at the gastric pouch outlet, the cause of the vomiting. This is a new entry: it explains the first entry rather than competing with it.
D. Nonhepatic hyperammonemia, reinstated; first result mildly raised; repeat pending.
Letters are used for the revision so that every reference below can name an item by its place in either version, for example "6 to A."
What Arrived in Between
Six pieces of information arrived between the two lists. Each is named with its time.
Hospital day 1, from 23:40: repeated glucose checks between 104 and 138 with no change in orientation.
Hospital day 2, 01:40: abdominal CT with no leak or collection and a narrowed pouch outlet.
Hospital day 2, 15:30: my eye examination, with gaze-evoked nystagmus to both sides, incomplete abduction in both eyes and no skew.
Hospital day 3, 07:50: MRI read as symmetric FLAIR change in both medial thalami and the periaqueductal gray, with clean diffusion images.
Hospital day 3, 14:00: routine EEG with diffuse slowing and no epileptiform discharges; cultures still sterile after two days.
Hospital day 4, 09:40: ammonia, drawn on ice, of 58 micromoles per liter against a laboratory upper limit of 47.
Moves Grouped by Kind
Taken off. Item 2, low blood sugar, came off on day 2 when fourteen hours of normal readings brought no improvement in orientation. Item 3, intra-abdominal sepsis, came off on day 3 with the CT and the sterile cultures at two days; it had been provisional since day 2. Item 4, promethazine effect, came off on day 2 because more than five elimination half-lives had passed since the last dose without any change. Item 5, posterior circulation stroke, came off on day 3 when the MRI showed no infarct; the symmetric eye findings the afternoon before had already moved it down. Item 7, seizures, came off on day 3 with the EEG and two days without any witnessed event.
Moved up. Item 6 went to A. It moved twice: first on day 2 at 15:30, when the eye findings brought the patient to four of the four criteria proposed for the diagnosis (Caine et al., 1997); and again on day 3, when the MRI showed the pattern that is specific for the condition (Galvin et al., 2010). At my examination this morning the nystagmus takes longer to appear and abduction is nearly full on both sides, which fits a response to thiamine.
Moved down within the list without leaving it. Item 1 went to B. Volume depletion is real and still being corrected, but it no longer competes for the explanation of the brain findings.
Added. Item C, the narrowed pouch outlet, entered on day 2 with the CT. Endoscopy on day 3 confirmed a stricture at the junction, which was dilated.
Putting an Item Back
Item 8, hepatic encephalopathy, was removed on day 2 on the basis of normal liver tests. That removal was correct for the liver and wrong for the question. The question was whether ammonia could be causing or adding to the confusion. After gastric bypass, ammonia can rise without any liver disease; a systematic review of this complication found 33 patients, most after this operation, and most with neurologic symptoms (Sakran et al., 2023). My removal used a reason that does not reach this form. Reinstating an item is the move a reader is most likely to doubt, so the reason for its return is stated as plainly as the reason for its removal.
It returns as D, renamed to describe what is actually being considered. The first result, 58 against an upper limit of 47, is mildly raised. A delayed or warm sample can raise ammonia falsely, so the result is being repeated on ice with immediate transport before anyone acts on it. If it is confirmed, the next steps are a nutrition review and the metabolic tests this team would order for that form; if it is normal, D comes off on a result rather than on an argument.
Still Not Settled
Two items remain open. The first is D, until the repeat ammonia is back. The second is whether A will leave lasting memory problems. Recovery was incomplete in 49% of the published bariatric cases, with memory deficits and gait difficulty among the most common lasting effects (Aasheim, 2008). The patient's orientation is improving, but recall of three words at five minutes is one of three this morning, and that is not yet a finished picture.
A whole blood thiamine level drawn before any thiamine was given is still at the reference laboratory. It will confirm or fail to confirm A, but at this stage it will not change treatment.
The plan for each open item is written beside it. For D, the repeat ammonia is drawn at 14:00 today on ice and walked to the laboratory; a normal result removes D, and a raised one leads to a nutrition consult and amino acid testing. For A, thiamine continues at the treatment dose until the eye findings stop improving, then moves to oral maintenance, with the surgical team's plan for long-term supplementation written into the discharge summary.
What the Revision Does Not Claim
The revised list is shorter, not certain. Diagnostic error includes failing to explain the problem in a timely way, not only giving the wrong name (Graber et al., 2005), and the two days it took for A to reach the top are part of what this note records. It also does not claim that the original list was careless. Six of its eight entries were reasonable on the night they were written; what failed was the order, and the reason given for it, which the review next week takes up.
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
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
Sakran, N., Parmar, C., & Pouwels, S. (2023). Nonhepatic hyperammonemic encephalopathy following bariatric surgery: A systematic review. Obesity Research & Clinical Practice, 17(6), 458-467. https://doi.org/10.1016/j.orcp.2023.11.001
What the NR 569 Week 7 assignment asks for
The Week 7 note asks you to place your original differential beside a revised one and explain the difference. Expect two to four pages. The original should appear as it was first written, ideally dated, and the revision below it, with both numbered or lettered so items can be referenced. The commentary then goes through each change, naming the specific information that caused it and when it arrived. Many prompts give a reinstated item, one taken off and later put back, its own paragraph. A closing section usually covers what remains uncertain and what you will check next. Rubrics often compare the original to your earlier submission, so improving it after the fact is noticed.
How this NR 569 Week 7 example is built
The sample prints the admission list in its original order and content, with entries shortened to labels, and then a four-item revision lettered A to D. A dated list of six pieces of information follows, from glucose checks to an ammonia result. Moves are grouped by kind: five entries taken off, each with its cause; thiamine deficiency moved up twice, with the eye examination and MRI as the causes; fluid loss moved down; and a stricture added after CT and endoscopy. A section explains why normal liver tests did not reach the nonhepatic ammonia cause. The note ends with the plan for each open item and what the revision does not claim.
Where the points sit in the NR 569 Week 7 rubric
Credit in Week 7 is tied to causes. Each move needs a named piece of information and a time; a move explained as the picture becoming clearer scores poorly, so every change here cites a result or an examination. Showing the original unaltered is worth marks of its own, because markers compare it with what was submitted earlier. The reinstatement row rewards a separate paragraph that admits why the item came off and why that reason failed, which this note supplies. Grouping moves by kind shows organization and lets a marker find each change in seconds. A closing section that keeps items open and names the next step for each satisfies the uncertainty criterion that many sections include.
NR 569 Week 7 help from the desk
In NR 569 Week 7, a common mistake is quietly improving the original list so the two versions agree and there is nothing to explain. Another is giving changes with no cause, or with a vague cause that would fit any patient. Writers often reorder the list and call it a revision without any item leaving or arriving. Reinstated items are skipped, which loses the row they exist for. Some notes end with a confident final answer instead of the open questions, which the uncertainty row penalizes. If your list moved differently, send both versions with dates; a note can be drafted around your own changes, giving each a cause and a time.
Get a NR 569 Week 7 example written to your instructions
Hand over the Week 7 instructions, the rubric and the earlier list you are revising, and a custom example written around them is back with you inside 24 to 48 hours, the first one free. If the earlier work was a Week 3 memo in the same section, say so, since the note is usually marked against that document's own headings.
More NR 569 papers and AGACNP samples
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- NR 569 Week 4: Discriminating Feature Brief
- NR 569 Week 5: Diagnostic Test Rationale
- NR 569 Week 6: Clinical Reasoning Journal
- NR 569 Week 8: Diagnostic Accuracy Review
- NR 567 Week 7: ICU Anticoagulation Case Analysis
NR 569 Week 7 questions, answered
What if nothing on my original list turned out to be right?
That is a strong note rather than a weak one, provided the commentary says where the list went wrong and what information would have put the eventual entry on it. What fails is treating the whole first version as a mistake, since several of its removals were probably sound and the note has to say which ones those were.
Does the revision have to be shorter than the original?
Usually, but not always. A revision that grew has to justify the growth, which is the reinstatement paragraph doing double duty, and sections accept it where the new information genuinely reopened something. What draws comments is a note that grew by adding entries nothing arrived to support, because that reverses the work the term has been doing.
Ours asks for a reflection at the end. What goes in it?
The part of the note that is about your own process rather than about the case, and it stays short in most rubrics. Name the removal you would make differently and the information you would have gone after sooner. An intention to slow down next time is not a change; a named difference in what you ask for first is, and only the second one gets marked.
Where can I find a free NR 569 Week 7 sample paper?
The full revised note, with the admission list unaltered, the lettered revision and the section on the ammonia cause put back, is published on this page.
Why is an item reinstated in the NR 569 Week 7 revised note?
Hepatic encephalopathy was removed on normal liver tests, but ammonia can rise without liver disease after gastric bypass, so it returns under a new name with a repeat level pending.