| Course | NR 569 Differential Diagnosis in Acute Care Practicum |
|---|---|
| Week | 8 |
| Paper type | Diagnostic accuracy review |
| 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 8
Where the Name Sat: A Diagnostic Accuracy Review of One Admission in Which Thiamine Deficiency Was on Every List and Ranked Low for Two Days
Student Name
College of Nursing, Chamberlain University
NR 569: Differential Diagnosis in Acute Care Practicum
Instructor Name
Month Day, Year
Where the Name Sat: A Diagnostic Accuracy Review of One Admission in Which Thiamine Deficiency Was on Every List and Ranked Low for Two Days
The Case and the Claim
This review takes one patient from my term on the hospital medicine service: a 47-year-old admitted in the ninth week after gastric bypass surgery, with three weeks of vomiting, four days of confusion and two falls. The final diagnosis was Wernicke encephalopathy from thiamine deficiency, supported by symmetric eye findings on hospital day 2, a characteristic MRI on day 3 and improvement on high-dose thiamine.
My claim is the first of the three possible: the list carried the answer from its first written version and ranked it low. The answer was not missing, and no removal took it off. It sat sixth of eight for most of a day, for reasons that I can now quote and examine.
Where the Name Sat
Table 1
Position of the Final Diagnosis on Each Version of the List
| Document | Time | Entries on the list | Position of the final diagnosis |
|---|---|---|---|
| Emergency department triage note (not mine) | Day 1, 18:30 | Impression: dehydration | Absent |
| Admission write-up | Day 1, 23:10 | 8 | 6 |
| Narrowing memo | Day 2, 10:00 | 3 | 3 |
| Discriminating feature brief | Day 2, 12:30 | Pair of 2 | One of the pair |
| Reasoning journal, entry 3 | Day 2, 15:30 | 7 | 1 |
| Test rationale memo | Day 2, 17:00 | 3 | 1 |
| Revised differential note | Day 4, 11:00 | 4 | 1 |
The table shows something the narrative could hide. Between the admission write-up and the narrowing memo, the name rose from sixth to third without any new evidence for it; it rose because five entries above it fell away. The move that actually mattered came at 15:30 on day 2, about 21 hours after the patient arrived.
Quoting My Own Document
The ranking was set by one sentence in the admission write-up, which gave two reasons for placing the entry low. The first was "no alcohol use." It was true and irrelevant. The setting that produced thiamine deficiency in this patient was weeks of vomiting after an operation that reduces intake and absorption. In a systematic review of 84 cases after bariatric surgery, frequent vomiting was a risk factor in 90% (Aasheim, 2008). The European guideline states that the diagnosis should be suspected in every condition that can lead to thiamine deficiency, not only in drinkers (Galvin et al., 2010). I used the most familiar setting of the disease as a test for whether it could be present. Croskerry (2003) describes this as a failure in which atypical presentations are discounted because they do not match the prototype.
The second reason was that the eyes were "full to casual tracking." Those words described an examination I had not performed. Watching the eyes follow a face is not the same as asking them to hold a position. When I asked them to hold, on day 2, nystagmus appeared in both directions. The phrase in the write-up recorded a normal finding that had never been tested.
The two reasons together made the ranking feel earned. Neither was.
The Decision That Was Not Mine
A second decision affected this case before I wrote anything. At triage, the patient received 25 g of dextrose for a glucose of 61, and thiamine followed nearly two hours later in a multivitamin infusion at a dose meant for prevention. Intravenous glucose without thiamine was a recorded risk factor in 18% of the published bariatric cases (Aasheim, 2008). The guideline advises thiamine before any carbohydrate when the diagnosis is suspected (Galvin et al., 2010). The triage team did not suspect it, and nothing in the triage note named the operation as a risk. I record this as a system observation, not a judgment of the triage nurse, because the correction for it belongs in an order set rather than in one person's memory.
Right for the Wrong Reason
The narrowing memo kept posterior circulation stroke on the list but ranked it lower, and the night before, my note had called the patient's age, 47, too young for a stroke of that kind. The MRI later showed no infarct, so the demotion was correct. The reason was not. Strokes in the vertebral and basilar territory occur at 47, including from arterial dissection, and an unsteady patient who is vomiting is exactly where these strokes are missed. Kattah et al. (2009) showed that a structured bedside eye examination caught strokes that early diffusion imaging missed, in people with acute vestibular symptoms.
A sound removal and a lucky one look the same once the outcome is known. If the MRI had shown a cerebellar infarct, the same sentence about age would have been the first line of a much worse review. I am counting this removal as an error in reasoning, even though it did not cause harm.
What the Case Says About the List
The list did its job in one sense: the answer was on it from the beginning. A list that holds the right name in sixth place for 21 hours does not, however, protect the patient during those hours. Diagnostic error, as defined in the 2015 report on improving diagnosis, includes an explanation of the patient's problem that arrives too late, not only one that is wrong (National Academies of Sciences, Engineering, and Medicine, 2015), so a delay with the correct name on the page still counts. Among 100 internal medicine errors reviewed by Graber et al. (2005), the cognitive factor seen most often was premature closure. My admission list did not close, but its order behaved as if it had.
The patient's outcome at discharge on day 9 was good but incomplete: walking with a cane, oriented, and recalling two of three words at five minutes. The whole blood thiamine level drawn before treatment returned low on day 7. The repeat ammonia was normal, and that entry came off on a result.
The Change at the End
One change, specific enough to check in my next practicum: for any patient admitted with vomiting after bariatric surgery, I will write thiamine deficiency on the first list by its setting, give the reason as the operation and the vomiting rather than the presence or absence of alcohol, and perform a gaze-holding eye examination in each direction before I write a word about the eyes. I will also ask for thiamine before or with the first glucose given. Whether the change happened will be easy to check: in my next admission write-up for such a patient, the sentence about the eyes will name the positions tested.
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
Croskerry, P. (2003). The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine, 78(8), 775-780. https://doi.org/10.1097/00001888-200308000-00003
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
Kattah, J. C., Talkad, A. V., Wang, D. Z., Hsieh, Y.-H., & Newman-Toker, D. E. (2009). HINTS to diagnose stroke in the acute vestibular syndrome: Three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke, 40(11), 3504-3510. https://doi.org/10.1161/STROKEAHA.109.551234
National Academies of Sciences, Engineering, and Medicine. (2015). Improving diagnosis in health care. The National Academies Press. https://doi.org/10.17226/21794
The Chamberlain NR 569 Week 8 instructions
The Week 8 review asks you to look back at one case from the term and judge your own diagnostic accuracy. Expect three to five pages focused on a single patient. Most prompts want the position of the final diagnosis on each version of your list, often in a table, followed by a clear claim: the list carried the answer and ranked it low, never carried it, or carried it and removed it. You then examine one decision, quoting your earlier documents directly. Many sections ask about a removal that was correct for the wrong reason. The review ends with one change you will make, specific enough that a preceptor could observe it in practice.
How this NR 569 Week 8 example is built
The example states its case and claim in two short paragraphs, then gives a table of seven documents with the time, the number of entries and the position of the final name. A paragraph notes that the name rose from sixth to third only because other entries fell. The writer quotes the two reasons from the write-up, explains why one was irrelevant and the other described an untested examination, and links them to published patterns of bias. A section treats dextrose before thiamine at triage as a system issue. Another examines the age-based stroke demotion. The review closes with the outcome at discharge and one change tied to the quoted errors.
Reading the NR 569 Week 8 grading rubric
The review wins its marks with position, not outcome. A paper that reports the patient did well and calls the reasoning sound has said nothing about where the name sat, so this sample opens with the table. The claim row asks for one of three statements, and the sample makes one plainly. Quoting earlier documents gives the argument evidence, and the quoted words here are examined line by line. The honesty row usually rewards a removal judged by its reasoning rather than its result, which the stroke section does. The final change earns credit when it is specific and checkable, like the gaze-holding examination named here, which a preceptor could watch for at the next admission.
Common NR 569 Week 8 mistakes, and how to avoid them
The NR 569 Week 8 review falls short when it summarizes the outcome and never states where the diagnosis sat on any list. Reviews that survey several cases briefly lose the depth the rubric wants. Paraphrasing earlier work instead of quoting it removes the evidence. Judging removals only by how the case ended misses the right-for-the-wrong-reason row. A closing promise to be more careful is too vague to observe, and so is a list of five lessons with no single change. If your term produced a different case, send your earlier lists and notes; a review can be organized around where your diagnosis sat, with quotations from your own documents and one concrete change.
Get a NR 569 Week 8 example written to your instructions
Send the Week 8 instructions and the rubric, plus the earlier lists you are reviewing if you still have them, and a custom example built to those is returned inside 24 to 48 hours, the first one free. Where the review covers a case you saw, a short account of how the list moved is enough for the desk to work from.
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 3: Differential Narrowing Memo
- NR 569 Week 4: Discriminating Feature Brief
- NR 569 Week 5: Diagnostic Test Rationale
- NR 569 Week 6: Clinical Reasoning Journal
- NR 569 Week 7: Revised Differential Note
- NR 567 Week 8: ICU De-Escalation Plan
NR 569 Week 8 questions, answered
We are asked to report an accuracy rate. Across what?
Across the versions of one case's list in most sections, not across the term. The usable figure is the place the eventual name held in each version and whether it improved, which is a hit rate of one list measured against itself over time. Anything wider turns into a count too small to say much. Give the desk that rubric row and the table gets built to it.
What if I never wrote the earlier lists down?
Then the review says so and works from what does exist: the assignments already submitted, whatever your section kept, and what you can date honestly. A review built on a rebuilt list has to label it as rebuilt, because an invented earlier version is the one thing here that would make the whole document worthless.
How is this different from the Week 7 revision?
Week 7 argues about the case and Week 8 argues about the list. The revision asks what the new information did; the review asks how the list behaved as a tool and what you would change about building the next one. Sections that set both in the same term mark the second on that shift, and a review that simply revises again loses the distinction.
Where can I find a free NR 569 Week 8 sample paper?
The complete accuracy review, with the position table across seven documents and the quoted reasons that kept thiamine deficiency low, is shown here.
Which removal was right for the wrong reason in the NR 569 Week 8 review?
The posterior stroke demotion. The MRI later showed no infarct, but the reason given at the time was the patient's age, which the review calls unsound.