| Course | NR 576 Differential Diagnosis in Adult-Gerontology Primary Care |
|---|---|
| Week | 3 |
| Paper type | Episodic visit note |
| Length | About 960 words, 5 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | MSN, Adult-Gerontology Primary Care NP (AGPCNP) |
| Updated | October 2026 |
Free sample paper for NR 576 Week 3
Episodic Visit Note: Two Night-Time Falls and Numbness Reaching the Fingertips in a 78-Year-Old With Long-Standing Diabetes, Placed Among the Established Condition, a New One and a Drug
Student Name
College of Nursing, Chamberlain University
NR 576: Differential Diagnosis in Adult-Gerontology Primary Care
Instructor Name
Month Day, Year
Episodic Visit Note: Two Night-Time Falls and Numbness Reaching the Fingertips in a 78-Year-Old With Long-Standing Diabetes, Placed Among the Established Condition, a New One and a Drug
Subjective
Chief complaint: two falls in the past month, both at night walking to the bathroom; numbness in both legs now up to the knees and, since spring, in the fingertips.
Has this happened before? No falls before this year. Numbness in the toes for about six years, which the patient describes as "like wearing socks." The change to the knees and the fingers is new within roughly six months.
What has changed in what the patient takes? No new prescriptions in the past year. Tamsulosin was restarted three months ago after a gap of several weeks when the patient ran out. Omeprazole 20 mg daily for nine years. Metformin 1,000 mg twice daily for 15 years. Amlodipine and hydrochlorothiazide unchanged. A daily multivitamin from the pharmacy for about two years.
How the week looks now against before: the patient used to walk the dog twice a day and now goes out once, holding the leash with both hands. Has stopped going down the basement stairs. Feels lightheaded on standing quickly, most mornings. The daughter reports more forgetting of names and appointments in the past few months.
Not reported: fainting, chest pain or a racing heart; no bowel or bladder change beyond the usual nighttime urination, no back pain, no weakness in the hands.
Objective
Blood pressure lying 142/78, pulse 72. Standing at one minute 118/70, pulse 80. Standing at three minutes 120/72, pulse 82. Systolic drop of 22 at three minutes, sustained.
Neurologic, legs: strength normal. Ankle reflexes absent on both sides; knee reflexes present and brisk on both sides. Vibration absent at the great toes, ankles and knees, reduced at the hips. Position sense absent at both great toes. Light touch reduced in a stocking distribution to mid-shin. Romberg: stable with eyes open, sways and steps within three seconds with eyes closed.
Neurologic, arms: vibration reduced at the fingertips, normal at the wrists. Position sense normal at the fingers. Strength normal.
Gait: wide-based, slow; turns in several steps.
Cognition: Mini-Cog 3 of 5, the same as in 2023.
Mouth: tongue smooth at the edges, not sore.
Skin and feet: no ulcers. Pulses present.
Recent results from the record: A1c 6.8% three months ago. Hemoglobin 11.2 g/dL; MCV 102 fL, from the same draw. No B12, folate or methylmalonic acid on file.
Medication Review
Metformin 1,000 mg twice daily, 15 years: relevant to B12 status. Omeprazole 20 mg daily, nine years: relevant to B12 status and to the long-term need. Tamsulosin 0.4 mg daily, restarted three months ago: relevant to standing pressure. Hydrochlorothiazide 12.5 mg and amlodipine 5 mg daily: relevant to standing pressure. Multivitamin with 400 micrograms of folic acid daily, two years: relevant to how a B12 deficiency would show in the blood. No sedatives, no opioids, no alcohol.
Assessment
The complaint has three possible homes: the established diabetic neuropathy, progressing; a new condition; or a drug. My assessment is that it belongs to more than one.
Part of it belongs to the established condition. The stocking sensory loss to mid-shin and the absent ankle reflexes fit a length-dependent diabetic neuropathy of long standing.
Part of it most likely belongs to a new condition, vitamin B12 deficiency affecting the posterior columns of the spinal cord. The reasons: severe loss of position and vibration sense out of proportion to the touch loss, a positive Romberg, brisk knee reflexes with absent ankle reflexes, fingertip involvement within months, a macrocytic anemia and long exposure to two drugs associated with low B12, metformin and a proton pump inhibitor (Aroda et al., 2016; Lam et al., 2013). Deficiency can affect the nerves, spinal cord and cognition as well as the blood (Stabler, 2013). This is a working assessment until B12 and methylmalonic acid are measured.
Part of it belongs to a drug. The falls happen on standing at night, the patient is lightheaded most mornings and the standing pressure falls by 22 mm Hg. Tamsulosin was restarted three months ago, and the risk of severe hypotension with tamsulosin is highest in the weeks after starting or restarting it (Bird et al., 2013). Hydrochlorothiazide may add to the effect.
Plan
Serum B12, methylmalonic acid, folate, complete blood count with smear and reticulocyte count today. Move tamsulosin to bedtime is not enough given the night-time falls; discuss with the patient a two-week trial off tamsulosin with a recheck of standing pressures and urinary symptoms. Advise a pause, seated, before standing up at night, and a light left on along the path to the toilet. Physical therapy referral for balance and gait. Return in two weeks with results.
Information Given to the Patient
I told the patient and daughter that the numbness may have more than one cause, that one possible cause is a low vitamin level linked to two long-term medicines and is treatable, and that the morning lightheadedness may be from the prostate medicine. They were given written advice on getting up slowly at night and a list of the symptoms that should bring a call before the next visit: a fall with injury, a faint, new weakness or difficulty passing urine.
Note on Scope
This note addresses the new complaint. Diabetes, hypertension and the prostate are documented as stable in the medication review and not reassessed here.
References
Aroda, V. R., Edelstein, S. L., Goldberg, R. B., Knowler, W. C., Marcovina, S. M., Orchard, T. J., Bray, G. A., Schade, D. S., Temprosa, M. G., White, N. H., & Crandall, J. P. (2016). Long-term metformin use and vitamin B12 deficiency in the Diabetes Prevention Program Outcomes Study. Journal of Clinical Endocrinology & Metabolism, 101(4), 1754-1761. https://doi.org/10.1210/jc.2015-3754
Bird, S. T., Delaney, J. A. C., Brophy, J. M., Etminan, M., Skeldon, S. C., & Hartzema, A. G. (2013). Tamsulosin treatment for benign prostatic hyperplasia and risk of severe hypotension in men aged 40-85 years in the United States: Risk window analyses using between and within patient methodology. BMJ, 347, Article f6320. https://doi.org/10.1136/bmj.f6320
Lam, J. R., Schneider, J. L., Zhao, W., & Corley, D. A. (2013). Proton pump inhibitor and histamine 2 receptor antagonist use and vitamin B12 deficiency. JAMA, 310(22), 2435-2442. https://doi.org/10.1001/jama.2013.280490
Stabler, S. P. (2013). Vitamin B12 deficiency. New England Journal of Medicine, 368(2), 149-160. https://doi.org/10.1056/NEJMcp1113996
The Chamberlain NR 576 Week 3 instructions
The Week 3 assignment asks for an episodic visit note on a new complaint in a patient with a long record. The note should be narrow. The subjective section stays with the new complaint and asks what the chart cannot: whether this has happened before, what has changed in what the patient takes and how life looks now compared with before. The objective section stays with the systems the complaint touches, plus anything an established condition puts at risk. The assessment must state which of three places the complaint belongs to: an established condition, a new condition or a drug, or which combination. Most rubrics want the record used in the reasoning, not only in the header.
How this NR 576 Week 3 example is built
The note's history covers the falls, the spread of numbness, a tamsulosin restart after a gap and changes in the patient's week, with pertinent negatives. A medication review gives each drug's relevance, including folic acid in a multivitamin. The examination records orthostatic pressures, a detailed sensory and reflex pattern, the Romberg, gait, cognition and the tongue, with the recent blood count. The assessment divides the complaint: stocking loss to the established neuropathy, posterior column signs and macrocytosis to a probable B12 deficiency and the standing drop to tamsulosin. The plan follows each part, and a section records what the patient was told. Nothing in the note repeats the full past history.
Where the points sit in the NR 576 Week 3 rubric
The costliest note works the new complaint in isolation, with the long record in the header and absent from the reasoning; this one uses the record in every part of the assessment. The reverse error, assigning the complaint to an established condition because they sit near each other, loses nearly as much, so this note argues what each condition would and would not produce. An assessment that names a diagnosis without saying where it belongs costs a row. Copying the whole chart into the history loses the focus criterion. Orthostatic pressures and a reflex pattern recorded in detail earn the examination marks.
Common NR 576 Week 3 mistakes, and how to avoid them
Many NR 576 Week 3 notes treat the new complaint as if the patient had no history. Others attach it to the nearest established diagnosis without argument. Histories often reproduce the full past record instead of asking what the chart cannot answer. Examinations wander across every system. Assessments name a condition but not whether it is new, old or drug-related. Plans may not follow the assessment. If your patient's complaint differs, send the record summary and what you found; a narrow note can be drafted that places the complaint among the three possibilities. Keep the note to about a page and a half, and let the plan follow the assessment line by line.
Get a NR 576 Week 3 example written to your instructions
Send the note template your classroom uses, the rubric, and whatever patient material your section handed out. A custom NR 576 Week 3 episodic visit note is written into that template and returned inside 24-48h, free on a first request, so you have a finished version to read your own draft against.
More NR 576 papers and AGPCNP samples
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- NR 576 Week 4: Clinical Reasoning Write-up
- NR 576 Week 5: Diagnostic Work-up Plan
- NR 576 Week 6: Case Presentation
- NR 576 Week 7: Atypical Presentation Write-up
- NR 576 Week 8: Diagnostic Synthesis Paper
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NR 576 Week 3 questions, answered
Is an episodic note allowed to be this short?
Usually, and length is rarely where the points are. Most classrooms define an episodic note by scope rather than by word count: one problem, the history that problem reaches, and nothing else. The example holds that boundary and puts its effort into the assessment. A note padded with review of systems detail no possibility needed is easy to spot and tends to read as uncertainty.
What if the new complaint clearly does belong to an established condition?
Write the reasoning anyway, because the assignment is the graded object rather than the answer. The example states which feature of the established condition accounts for the complaint and at what point in its natural history that becomes expected. An examined fit and an unexamined assumption look the same on the page, and a section cannot usually tell them apart without that sentence.
Do the other possibilities have to appear if one explanation is strong?
In many sections yes, and briefly is enough. The example keeps one or two alternatives visible with a clause each saying what keeps them alive, and names the finding that would raise either. What loses points is closing the note as though only one explanation had ever been available, since the week is built on a patient for whom that is rarely true.
Where can I find a free NR 576 Week 3 sample paper?
The full episodic note on falls and numbness in the 78-year-old, with orthostatic pressures and a three-part assessment, is published on this page.
Where does the NR 576 Week 3 note place the falls?
Partly with a drug, tamsulosin restarted three months earlier with a 22-point standing drop, and partly with lost position sense from a probable B12 deficiency.