| Course | NR 576 Differential Diagnosis in Adult-Gerontology Primary Care |
|---|---|
| Week | 5 |
| Paper type | Diagnostic work-up plan |
| Length | About 910 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 5
Diagnostic Work-Up Plan for Falls and Spreading Numbness in a 78-Year-Old: Each Move Paired With the Possibility It Settles, Including a Dated Withdrawal of Tamsulosin
Student Name
College of Nursing, Chamberlain University
NR 576: Differential Diagnosis in Adult-Gerontology Primary Care
Instructor Name
Month Day, Year
Diagnostic Work-Up Plan for Falls and Spreading Numbness in a 78-Year-Old: Each Move Paired With the Possibility It Settles, Including a Dated Withdrawal of Tamsulosin
The Possibilities Being Decided
The plan serves three possibilities from the reasoning write-up: vitamin B12 deficiency affecting nerves, spinal cord and blood; the established diabetic neuropathy, progressing; and orthostatic hypotension from tamsulosin, perhaps with hydrochlorothiazide, causing the falls. Each move below names which of these it addresses.
The Moves
Table 1
Work-Up Moves, the Possibility Each Addresses and the Result That Would Settle It
| Move | Possibility it addresses | Result that would settle it |
|---|---|---|
| Serum B12 | B12 deficiency | Below about 200 pg/mL supports it; above about 400 makes it unlikely; between settles nothing alone |
| Methylmalonic acid, with creatinine | B12 deficiency at tissue level | Raised with normal kidney function supports it; normal argues against |
| Complete blood count with smear and reticulocytes | B12 deficiency affecting the blood | Macrocytosis with oval macrocytes and hypersegmented neutrophils supports it |
| Folate | Folate deficiency as an alternative cause of macrocytosis | Low folate would add a second deficiency; normal leaves B12 as the leading cause |
| Orthostatic vital signs at this visit and at two weeks | Drug-related orthostatic hypotension | A sustained drop of 20 systolic or 10 diastolic within three minutes confirms orthostatic hypotension |
| Tamsulosin withheld for two weeks, from today | Drug-related orthostatic hypotension | Resolution of the standing drop and of morning lightheadedness supports the drug; no change argues against it |
| Interval of two weeks, watching for night-time falls and urinary symptoms | Drug-related orthostatic hypotension, and the cost of withholding | No falls and tolerable urinary symptoms support the withdrawal |
| Monofilament, vibration and position sense recorded at baseline | Both neuropathy explanations | Serves as the baseline against which any response to replacement is judged |
Timeline
Day 0, today: blood tests drawn; tamsulosin withheld; orthostatic pressures recorded; baseline neurologic findings written in the note. Day 3 to 5: results reviewed by me and my preceptor; the patient called with the B12 and methylmalonic acid results either way. Day 14: return visit; standing pressures repeated; fall and symptom diary reviewed; decision on tamsulosin; omeprazole discussed. Month 3: neurologic examination repeated against the baseline if replacement has started.
Who Does What
The patient and daughter keep the diary. The clinic nurse calls on day 7 to ask about falls and urinary symptoms. I review results with my preceptor and make the day 3 to 5 call. Urology receives a letter if tamsulosin is not restarted, so that an alternative for the prostate can be discussed.
Interpreting Unremarkable Results
Each test is interpreted whether or not it is abnormal. A normal B12 with a normal methylmalonic acid would make the deficiency unlikely and send the reasoning back to the established neuropathy and to other causes of posterior column loss. A borderline B12 with a raised methylmalonic acid would support the deficiency even though the B12 alone looks acceptable, which is the most likely result in this age group (Stabler, 2013). A normal standing pressure at two weeks off tamsulosin would support the drug explanation only if the first reading was abnormal, which it was.
The Withdrawal, With Its Period and What to Watch
Tamsulosin is withheld for two weeks from today, with the patient's agreement, as a test rather than a treatment decision. During the two weeks, the patient and daughter will record night-time falls or near-falls, morning lightheadedness on a scale of none, mild or bad, and urinary frequency at night. Bird et al. (2013) found the excess risk of severe hypotension concentrated in the first weeks of starting or resuming tamsulosin, and this patient restarted it three months ago after a gap, so the timing fits. At two weeks the standing pressures are repeated. If the drop has resolved and the falls have stopped, the drug was a cause; the decision about long-term prostate treatment then goes to the patient and urology. If nothing changes, the drug explanation weakens and tamsulosin can be restarted.
The Proton Pump Inhibitor
Omeprazole is not withdrawn yet. Acid suppression over years is a recognized contributor to low B12 (Lam et al., 2013), and the geriatric prescribing criteria discourage continuing it past about two months unless there is a clear reason (American Geriatrics Society Beers Criteria Update Expert Panel, 2023). But changing two drugs at once would make the two-week interval impossible to read. The omeprazole decision is scheduled for the next visit, once the tamsulosin test is complete.
What the Plan Does Not Do
No result on any path will be used to stop metformin. Metformin's benefit for this patient's diabetes stands, and B12 deficiency, if confirmed, is treated by replacement while metformin continues. The plan also does not order nerve conduction studies or spinal imaging at this stage; they would be considered if B12 and methylmalonic acid are normal and the posterior column signs remain unexplained.
Patient Preferences
The patient agreed to the blood tests and to the two-week trial off tamsulosin, after asking whether the nighttime urination would get worse. We agreed that if it became intolerable, the patient would call and we would reconsider. The patient declined referral for nerve conduction studies at this stage, which fits the plan.
References
American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052-2081. https://doi.org/10.1111/jgs.18372
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 5 instructions
The Week 5 assignment asks for a work-up plan for the possibilities your reasoning left open. Expect a short document with a long justification column. Every item is written as a pair: the move, then the possibility it would settle and the result that would settle it. Moves that are not orders belong too, such as a planned withdrawal with a date or an interval in which one specific change is watched for. Most prompts want every result interpreted whether or not it is abnormal, and want any drug possibility argued earlier to have a move that tests it. Many also ask what the plan will not do, and how the patient's preferences shaped it.
How this NR 576 Week 5 example is built
The plan opens by naming three possibilities: B12 deficiency, progressing diabetic neuropathy and tamsulosin-related orthostatic hypotension. A table gives eight moves, from serum B12 and methylmalonic acid to the tamsulosin withdrawal and a two-week watching interval, each with the possibility and the settling result. A timeline and a list of who does what follow. A section interprets normal and borderline results. The withdrawal section gives the period, the diary and what happens at two weeks either way. The omeprazole change is deliberately held so the interval can be read. A statement that no result will stop metformin and a note on the patient's preferences close it. Every move can be traced to a named possibility.
Reading the NR 576 Week 5 grading rubric
Points drain fastest from a plan built around the complaint, with a standard panel ordered because numbness usually gets one; this plan ties each move to a named possibility. Silence about the drug branch costs the next share, and the tamsulosin withdrawal tests it directly. Results interpreted only if abnormal lose a row; this plan interprets normal and borderline results. A withdrawal without a period or a defined change to watch for is half a move, while this one has both. Holding a second drug change to keep the interval readable shows design. A plain statement about metformin and recorded patient preferences complete the criteria.
NR 576 Week 5 help: mistakes that cost points
The weakest NR 576 Week 5 plans list routine tests for the symptom without linking them to possibilities. Others raise a drug explanation earlier and then never test it. Many plans promise to interpret results only if abnormal. Withdrawals are often proposed with no date, no duration and nothing specific to watch. Changing two medicines at once makes the result unreadable. If your possibilities differ, send them with the patient's medicines; a plan can be laid out with each move paired with the result that would settle it. Give the withdrawal a start date, a length and a diary, and change only one drug at a time so the interval can be read.
Get a NR 576 Week 5 example written to your instructions
Send the scenario your instructor supplied, the rubric, and any table or template your classroom expects the plan in. We write a custom NR 576 Week 5 diagnostic work-up plan into it and return the finished document inside 24-48h, free on a first request, with every move tied to the branch it would close.
More NR 576 papers and AGPCNP samples
- NR 576 Week 1: Old Label Versus New Complaint Post
- NR 576 Week 2: Problem List Review
- NR 576 Week 3: Episodic Visit Note
- NR 576 Week 4: Clinical Reasoning Write-Up
- NR 576 Week 6: Case Presentation
- NR 576 Week 7: Atypical Presentation Write-up
- NR 576 Week 8: Diagnostic Synthesis Paper
- NR 568 Week 5: Deprescribing Plan
NR 576 Week 5 questions, answered
Should the plan weigh whether the patient wants any of this?
That belongs to a different conversation and the example stays clear of it. What this document establishes is what each move would settle and what stays open without it, put concretely enough that anybody weighing the wider question has something to weigh. Sections asking for preferences and capacity to be considered usually place that discussion elsewhere, and a plan like this feeds it rather than replacing it.
How is a planned withdrawal written without turning into a treatment plan?
By keeping it a question. The example names the agent, the period over which a change would be expected, the specific change being watched for, and the point at which the observation is complete. What it does not do is decide what the regimen becomes afterward, because that is a separate decision with its own reasoning, and plans that drift into it stop justifying the observation they began with.
Does everything on the plan need a citation?
The claims about what a result establishes and what an agent typically produces do, since those come from published material rather than from the case. The example keeps references beside those particular sentences. Ordering decisions argued from this patient's own record need none, and adding one there tends to signal the reasoning came from a source instead of from the case.
Where can I find a free NR 576 Week 5 sample paper?
The complete work-up plan with eight paired moves, a dated tamsulosin withdrawal and the interpretation of unremarkable results is published on this page.
Why is omeprazole not stopped at the same time in the NR 576 Week 5 plan?
Changing two drugs at once would make the two-week interval impossible to read, so the omeprazole decision waits until the tamsulosin test is complete.