NR 576 Week 6 Case Presentation Script Example

Case Presentation Script: The Record Called It Diabetic Neuropathy for Six Years, and Here Is Where That Account Changes, Told One Line of Evidence at a Time

Student Name

College of Nursing, Chamberlain University

NR 576: Differential Diagnosis in Adult-Gerontology Primary Care

Instructor Name

Month Day, Year

Case Presentation Script: The Record Called It Diabetic Neuropathy for Six Years, and Here Is Where That Account Changes, Told One Line of Evidence at a Time

Opening, About 30 Seconds

This patient is 78, diabetic since 2007, and came to clinic after two falls at night. For six years, the record has explained the patient's numb feet as diabetic neuropathy, and for four years it has carried "dizziness" as a diagnosis. I am going to tell you where that account stops being enough. By the end you will hear three explanations for this patient's problem instead of one, and one of them is a drug the patient restarted three months ago.

What the Record Said, About 45 Seconds

The record's story was simple. Diabetes since 2007. A monofilament test in 2019 found reduced sensation at the toes, and "diabetic peripheral neuropathy" went on the list. Dizziness was added in 2021 after an urgent care visit. Anemia was added in 2022 from a hospital discharge summary as "likely anemia of chronic disease." Nobody revisited any of them. When the falls began, the obvious reading was that the neuropathy had worsened.

Where the Account Diverges, About 20 Seconds

The divergence is one finding: the patient lost position sense at the toes, and fell with eyes closed within three seconds, while touch was reduced only to mid-shin. Diabetic neuropathy of this degree does not usually take position sense first. That is where the record's account stopped being enough.

First Line of Evidence: The Spinal Cord, About One Minute

Let me finish this one before starting the next. Position and vibration travel in the posterior columns of the spinal cord. When those columns are affected, people rely on their eyes to know where their legs are, which is why this patient falls in the dark and why the Romberg test was positive. The knee reflexes were brisk, while the ankle reflexes were absent. Brisk knees suggest the spinal cord; absent ankles suggest the peripheral nerves. Both can be present at once. The fingertips became numb within six months. Together these point to something affecting the spinal cord as well as the nerves, over months rather than years.

Second Line of Evidence: The Blood, About 45 Seconds

Now the second line. The hemoglobin was 11.2, and the red cells were large, with a mean volume of 102. The record had called this anemia of chronic disease, but that label was written during an infection and never tested. Anemia of chronic disease usually produces normal-sized or small cells, not large ones. Large red cells and posterior column signs together suggest a common cause.

Third Line of Evidence: The Medicines, About One Minute

The third line. The patient has taken metformin for 15 years and omeprazole for nine. Both are associated with low vitamin B12. In the Diabetes Prevention Program follow-up, the odds of deficiency climbed with each year on metformin (Aroda et al., 2016), and years of acid suppression have also been linked to it (Lam et al., 2013). Vitamin B12 deficiency affects the spinal cord, the nerves, the blood and sometimes memory (Stabler, 2013). The results came back last week: B12 was 168 pg/mL, low, and methylmalonic acid was raised at 0.62 micromoles per liter, with normal kidney function.

Fourth Line of Evidence: Standing Up, About 45 Seconds

The last line is separate. The patient's blood pressure fell by 22 points on standing and stayed down at three minutes. That meets the definition of orthostatic hypotension. The patient restarted tamsulosin three months ago after running out, and severe low blood pressure on tamsulosin clusters in the first weeks after it is started or resumed (Bird et al., 2013). After two weeks off it, the standing drop was 6 points, and the patient had no falls.

The Revised Account, About 45 Seconds

So the account has three parts. The long-standing diabetic neuropathy is real and explains the stocking numbness and the absent ankle reflexes. Vitamin B12 deficiency, linked to two of the patient's medicines, explains the lost position sense, the positive Romberg, the brisk knees, the fingertips and the large red cells. And tamsulosin, restarted three months ago, explains the falls on standing. The record's single label covered one of the three.

What Happens Next, About 30 Seconds

B12 replacement has started. Metformin continues. The omeprazole decision is next visit. Tamsulosin stays off while the patient and urology discuss an alternative. We will repeat the position sense and Romberg at three months to see how much of the imbalance improves.

Expected Questions

"Why not stop metformin?" Because its benefit for the diabetes stands, and the deficiency is treated by replacement. "Could the neuropathy be all B12?" Possibly not; the stocking loss and absent ankle reflexes predate the change, and some may be diabetic. "Will the patient recover?" Some improvement is likely, but long-standing damage may recover only partly.

Slide Plan

Slide 1: the patient in one line and the record's three labels. Slide 2: the one finding where the account diverges, position sense lost with touch largely kept. Slide 3: the blood, two numbers. Slide 4: the medicines, two of them, with years of use. Slide 5: the standing pressures before and after stopping tamsulosin. Slide 6: the three-part account. Each slide carries a few words and numbers only; the reasoning is spoken. There is no slide for the history of the record, because the opening states it in a sentence and the room does not need it again.

Note on Delivery

This is written to be spoken in about seven minutes, timed twice in rehearsal. Slides show only the four findings that diverge from the record's account and the three-part summary, not the text spoken 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