MN552 Discussion Topic: How to Approach the Clinical Encounter and Medical Ethics

A 16-year-old male was brought to the emergency department (ED) in police custody for psychiatric evaluation. His girlfriend called 911 because he was hearing voices and threatening to shoot her. He reportedly had a history of schizophrenia and had stopped taking his medications. On arrival, he was attempting to leave the ED: "Let me go! I know my rights!" While in the ED, he stated that he did not want his mother or his psychiatrist to know that he threatened to shoot his girlfriend and did not want this to be in his medical record. In one page or 300 words reflect on how you would approach this dilemma.

Discussion Rubric: Thorough identification of the importance of the subject matter to the individual, clinical, and professional. Supports discussion concepts through personal experience and evidence-based information. Provides a well-written reflection that is clearly connected to the outcomes and clinical insight. With thorough reflection and content. No grammar, word usage, or punctuation errors. Overall style is consistent with professional work. Writing style facilitates communication. APA format. Provides three references that are relevant to the content and published within the last five years.

BUY PURDUE NURSING ASSIGNMENT HERE:  MN552 Discussion 

Part 2

MN566 Discussion topic: Diagnostic Reasoning

Clinical decision making is the process by which we determine who needs what and when. While not exactly arbitrary, this exercise can be quite subjective. Each provider compiles their own data (hence the emphasis on learning to perform an accurate H&P) and then constructs an argument for a particular disease state based on their interpretation of the "facts." The strength of their case will depend on the way in which they gather and assemble information. There may then be no single, right way of applying diagnostic and therapeutic strategies to a particular case. Medicine involves playing the odds, assessing the relative chance that a patient is/is not suffering from a particular illness. Codifying the way in which providers logically approach problems and deal with this uncertainty is a difficult task. Relying solely on the classic features of a disease may be misleading. That is because the clinical presentation of a disease often varies: the symptoms and signs of many conditions are non-specific initially and may require hours, days, or even months to develop.

Generating a differential diagnosis; that is, developing a list of the possible conditions that might produce a patient's symptoms and signs, is an important part of clinical reasoning. It enables appropriate testing to rule out possibilities and confirm a final diagnosis.

This case portrays a poor patient outcome after a misdiagnosis.

Case scenario

A previously healthy 35-year-old lawyer presents to a primary care office with a chief complaint of chest pain and a non-productive cough. The pain started suddenly two hours prior to coming to the office while the patient was sitting at his desk. The patient describes the pain as sharp in nature, constantly present but made worse with inspiration and movement, and with radiation to the base of the neck. His blood pressure in the right arm and other vital signs are normal

On physical examination, the only findings of note are chest wall tenderness and a faint cardiac murmur. The ECG in the office is normal. The patient is observed for an hour in the office and assessed. He is diagnosed with viral pleurisy and sent home on non-steroidal analgesics.

The following day the patient collapses at home and cannot be resuscitated by the paramedic service. An autopsy reveals a Type 1 aortic dissection with pericardial tamponade.

Discussion Assignment: In 300 words or a page

Developing a list of possible conditions that might produce a patient's symptoms and signs is an important part of clinical reasoning.

As an NP in primary care, what would you have done differently?

Discuss the importance of creating a list of differentials for this patient. How could it have changed this outcome?

If a serious diagnosis comes to mind based on a patient's symptoms:

• Ask yourself: Have you considered the likelihood of a serious diagnosis and whether it needs to be ruled out by testing or referral?
• Because many serious disorders are challenging to diagnose, have you considered ruling out the worst-case scenario?
• Ask yourself: Do you have a sufficient understanding of the clinical presentation to offer an opinion on the diagnosis?
• What other diagnoses could it be? How might the treatment to date have altered the patient's outcome?
• What other diagnostic and laboratory or imaging was needed in order to make a complete differential list? What support tools would you consider using in helping to create a differential diagnosis list?
• Are you familiar with the current clinical practice guidelines for the investigation of a suspected condition such as chest pain?
• Please support with up-to-date evidence-based standard of care guidelines that are less than 5 years old.

Discussion Rubric: Thorough identification of the importance of the subject matter to the individual, clinical, and professional. Supports discussion concepts through personal experience and evidence-based information. Provides a well-written reflection that is clearly connected to the outcomes and clinical insight. With thorough reflection and content. No grammar, word usage, or punctuation errors. Overall style is consistent with professional work. Writing style facilitates communication. APA format. Provides three references that are relevant to the content and published within the last five years.

 Read MN552 Discussion Free Sample Here

Part 1

MN552 Discussion Topic: How to Approach the Clinical Encounter and Medical Ethics

It is evident that the patient is suffering from schizophrenia, The DSM-5 diagnostic manual criteria for a patient with schizophrenia include the presence of the patient symptoms for over a period of 6 months, depicting hallucinations, delusions, disorganized speech which should be present, or gone on for at least a month (Redinger & Gibb, 2020). Others include displaying a catatonic or disorganized behavior, flattened emotions and inadequate communication. Based on the case report these are the symptoms that the patient depicted which indicate that it was definite he had schizophrenia. After assessing the symptoms I will then go ahead and first ensure client safety is guaranteed, since patients with schizophrenia are prone to injury because of the visual and auditory hallucinations which are also caused by abnormalities in the process of the brain processing sensory information (Chiffi, 2020). The hallucinations such as they ones prompting the patient to dare to shoot his girlfriend can interfere with the patient ability to function in daily life. It is also likely that the condition causes him to be express violent behavior which could cause injuries to himself and those around him, so ensuring his safety is very important (Redinger & Gibb, 2020). I am also going to help the client to identify needs that might underlie hallucinations. This is because hallucinations are likely to reflect on the needs for power, anger, sexuality, and self-esteem (Herring, 2022). It is also important to acknowledge that the exist problem is a burden to the patient mind  and one of the most important thing to do will be to ensure that I also explain the problem to his girlfriend, the police and his family members (Redinger & Gibb, 2020). This is because the patient may not understand what is happening to them and will be afraid to tell those people that are close to them, for fear of burdening them. Lastly I will also ensure that I document everything client says, which includes what he feels, the triggers of her thoughts and imaginations, and what he does to get out of it. 

 References

Chiffi, D. (2020). Clinical hypotheses in diagnostic and prognostic reasoning. Clinical Reasoning: Knowledge, Uncertainty, and Values in Health Care, 47-62. https://doi.org/10.1007/978-3-030-59094-9_4

Herring, J. (2022). 6. Mental health law. Medical Law and Ethics, 262-303. https://doi.org/10.1093/he/9780192856562.003.0006

Redinger, M. J., & Gibb, T. S. (2020). Counter-transference and the clinical ethics encounter: What, why, and how we feel during consultations. Cambridge Quarterly of Healthcare Ethics, 29(2), 317-326. https://doi.org/10.1017/s0963180119001105

 Part 2

MN566 Discussion topic: Diagnostic Reasoning

Developing a list of possible conditions that might produce a patient's symptoms and signs is an important part of clinical reasoning.

As an NP in primary care, what would you have done differently? As the NP it would be very important for me to consider the differential diagnose of the patient based on the different symptoms primary his chest pain. I am also going to look at the different life threatening conditions such as pulmonary embolism and aortic dissection and myocardial infarction Jackson et al., 2020). 

Discuss the importance of creating a list of differentials for this patient. How could it have changed this outcome?

The importance of creating a number of differential diagnosis is very important for this patient as it will help in ruling out any fictitious and malingering disorder. This often happen when the patient is either afraid of or is intentionally deceiving the NP Jackson et al., 2020). It is possible that the patient may also be making up the symptoms since he may not understand the questions (Sprigings, 2018). Working through differential diagnosis will help in finding out the correct illness, thus cooperate with the patient. Often it could be challenging to find out if the patient is exaggerating or making symptoms thus it becomes important to single our every possible condition from the subjective data Jackson et al., 2020). The first step that I would use would be to gather clues regarding the patient health by asking questions regarding his symptoms such as how he feels, when the symptoms began and what makes them better or works, I will walk the patient through the OLDCARTS to ensure that I get all the subjective data (Jackson et al., 2020). Secondly I am going to process physical exam and collect information related to his chief complaint which will help rule out several conditions (Sprigings, 2018). I will then put together the differential diagnosis list in relation to the symptoms, health, and lifestyle (Cerrato & Halamka, 2020). The fourth action would be to order tests which will confirm and rule out various conditions and come up with symptoms that relate the diagnoses. This will help come up with the main diagnosis of the patient.  

References

Cerrato, P., & Halamka, J. (2020). Clinical reasoning and diagnostic errors. Reinventing Clinical Decision Support, 1-24. https://doi.org/10.1201/9781003034339-1

Jackson, J. M., Skelton, J. A., & Peters, T. R. (2020). Medical students’ clinical reasoning during a simulated viral pandemic: Evidence of cognitive integration and insights on novices’ approach to diagnostic reasoning. Medical Science Educator, 30(2), 767-774. https://doi.org/10.1007/s40670-020-00946-9

Sprigings, D. (2018). Diagnostic reasoning. Oxford Medicine Online. https://doi.org/10.1093/med/9780199568741.003.0001