NR 511 – Differential Diagnosis and Primary Care Practicum

NR 511 Assignment Summary

Probably one of the most asked question at the beginning of this class is logging MyEvaluations and where the MyEvaluations is.

Log in to https://portal.chamberlain.edu/login.
On the left column, you will see “Resources”
Then “My degree and course”
Then, under the “Practicum/Clinical Logging tool – MyEvaluations”
Then you will be directed to another website that would like this.
Finally, you are at the logging website.
Why did they make it so complicated? lol. Tell me about it… -_-

You are ok to log 1 hour/pt in NR511 and gradually decrease the time/pt. I had a few pt with slightly more than an hour due to the pt’s complexity. As long as your documentation supports, then you can log more than an hour. For some instructors, they get very picky and will ask you to start decreasing time/pt sometime around Week 5 or so. Yes, you are allowed to log 1 hr/pt but to some instructors, such rules do not apply to them. Welcome to CU. -_-
Toward the end of the practicum, I started to log some 50 min/pt for simple cold-like symptoms and 30 min/pt for sports physicals. As long as your time is reasonable, you shouldn’t have a problem.

When you go to the clinic, you will need this stuff for you to fill in the logs easily and get through the day.

1. Clinical log – Template
2. CPT_CODES
3. Epocrates could be useful and here is the 50% discount code (Student50percentoff) for 1-year subscription. No, I am not affiliated. If it doesn’t work, you can call them and ask for one. They will be happy to give you a new code.
4. Take your stethoscope, preferably a cheap one. I have been using the disposable one from my ER. No one cares. Don’t lose your expensive one.
5. Some people like to use H&P notebooks such as Perfect H&P Notebook or H&P Notebook.

Once you get used to it, you won’t need the clinical log template.

FAQ/Tips

1. How many hours? You must have at least 125 hours by the middle of Week 8, which is about 18 hours/week logged.
2. Can you log more than 125 hours in 1 term? No.
3. Logging tip – Remember that it took you about 20~25 mins to complete the head-to-toe assessment during the Immersion. Then you come up with DDx (differential diagnosis), discuss with the preceptor, then treat/educate pt, then you document. So, 1 hour/pt is reasonable. In order to encounter as much pt as possible, you should log MyEvaluations later. Sometimes, your clinic would let you chart on their charting program and some don’t. I got to chart on their charting system. So, I got to copy and paste the chart on a note pad or email WITHOUT PT’S PERSONAL INFORMATION then logged on MyEvaluations later. More detail it is, the better for your SNAPP presentation.
4. Make sure to go to the clinic as much as possible at the beginning of the term so that you can have some time later for making up more hours if your instructor somehow does not approve some of the logged hours. (Yes, it does happen to some students.) I aimed to complete the 125 by the end of Week 5.
5. Peds/Women health – Log as much as you can when you get a chance. You must have 15% (about 110 hours) on each peds and women health.
6. How can I handle work/practicum/study? Well, I must say, shush! lol I had 1 full-time job, 1 part-time teaching job, my wife in nursing school with tons of questions, and this class. Some people handle with 5 kids with a full-time job. You may not have a “quality” life but it can be done. Just prioritize what you must do vs what you want to do.
7. Hours in the clinic doesn’t not equal to hours you can log. It’s all about hours you spend with pt + charting + discussion with the preceptor.
8. Make sure to include CPT code.
9. Log your hours diligently. Do not get behind. You will regret it! =p
10. Remind your preceptor for midterm/final evaluations. If these are not done on time, you may fail the class!
11. Shadowing counts for the practicum hour? Absolutely not! There are 15 alternative hours for reviewing med, making calls to pt, and going over labs but those are pretty much no use. I have 0 on that. Just focus on seeing the pt and chart those hours.
12. What happens if you cannot fulfill 125 hours? You fail the class entirely and you must retake NR511. Get it done early!!

Below is one of my sample logs. I have not had any rejection from all of the clinical evaluations by all instructors. I once had an opinion of being too detailed by an instructor but she was ok with that much of detail. Of course, the below content goes to the “comment” section of MyEval and all the selecting parts are also completed.

38LW

CPT: 99214

Chief Complaint(s): 1. Follow up on ER visit for right arm numbness and loss of vision, referral to neurologist. 2. Discuss checking thyroid and iron for fatigue and dizziness x few months, hx of low iron.
Pt denies over the past 2 weeks of feeling down, depressed or having little interest or pleasure in doing things. (per PHQ-2 screening tool)

History of Present Illness: 1. Dizziness
Pt was recently seen in ED due to acute onset right arm numbness and “floaters”/ loss of vision bilaterally. Pt had a HR of 49 and otherwise Head CT, EKG, aPTT, CMP, CBC were WNL. Pt admits to increased stress and anxiety around ED visit. Pt is still having dizziness and lightheadedness upon standing for 5 days. All other presenting symptoms in including paresthesia, anxiety, and change in vision have not returned since 1 episode leading to ED visit. Of note, pt is very active in exercise and sport. Pt confirms quality hydration status. Denies palpitations, SOB.

Allergies: No Known Allergies Family History: Brother 1: Thyroid Disease Father: Hypertension, Hypothyroidism Paternal Grandfather: Thyroid Disease Social History: Alcohol: 1 drinks/week Exercise: Daily Caffeine: Coffee 1x/day Smoking: Never smoker Review of Systems: General Fatigue. Denies fever, chills, night sweats Skin Denies skin changes; itching; rashes; sores Head Denies trauma; headache, nausea, vomiting, visual changes Cardiac Denies chest pain, palpitations, hypertension, dyspnea on exertion, edema Respiratory Denies shortness of breath, wheeze, cough, sputum Neurologic Dizziness upon standing. Denies headaches, loss of sensation, numbness, tingling, tremors, weakness/paralysis, fainting/blackouts, seizures Hematologic Denies anemia Endocrine Denies excessive sweating, polyuria, polydipsia

OBJECTIVE Vitals: Systolic: On examination – Systolic BP reading: 118 Diastolic: On examination – Diastolic blood pressure reading: 80
T: 97.8 F. Pulse: 64 / min Resp: 16 / min BP: 118 / 80 mmHg WT: 150 lbs HT: 5’10” BMI: 21.52
Exams: General Alert and oriented, In no acute distress, well developed, well nourished Head/Face NC/AT Eyes PERRLA, EOMI, No injection or icterus Resp CTA bilaterally, no wheezes, rhonchi, or rales Cardio RRR, normal S1, S2, no murmurs, rubs, or gallops (S3, S4) Neuro Motor/Sensation grossly normal, Non-focal Musculo No muscle atrophy or weakness, No focal areas of tenderness Extremities No clubbing, cyanosis, or edema Skin Warm, dry, no rashes Psych Alert and cooperative, Normal affect, Thoughts appear congruent and appropriate

ASSESSMENT Assessment for this encounter: Unspecified visual loss(H54.7) Paresthesia of skin(R20.2) Dizziness and giddiness(R42) Other fatigue(R53.83)

1. Re-occuring Dizziness/ Recent ED visit
–Pt referred to Cardiology for further assessment
–Pt referred to Neurology for paresthesias, vision loss in absence of cause of CVA workup
–LABS TSH, T4, T3 due to family history
–Will call patient with abnormal lab results
–Pt educated on maintaining adequate fluid intake
–ED precautions reviewed with patient
–RTC as needed

Week 1 exam – Content of the exam is not hard at all but the way the questions worded are very confusing! Make sure that you know every bit of words from the video lectures. Questions are very nitpicking!

VICE Call – Phone call assignment. Around week 3, you should be getting an email from your professor for arranging time/date for the VICE call. The call will last less than 30 minutes (mine lasted about 25 minutes including chit-chatting for ice breaker) and you have 2nd chance to call if you miss the 1st scheduled date/time.

Depending on your professor, some professor would let you pick your patient or professor will pick a patient from the logged patients from “My Evaluation”.

You are basically going to do SNAPPS. In my case, I was allowed to pick a patient prior to the call. (If you get to pick your own pt, make sure that you pick easy pt.) I reviewed the patient’s report prior to the call and practiced SNAPPS. I pre-typed what I wanted to present on a screen and went through one by one. At the time of scheduled date/time, you will call you professor that professor provided you and do the SNAPPS. Only one part that was different from me was, I did the P (Probe) part at the end. The phone on the professor’s side was left mute while I was presenting until I went down the list of SNAPS (Probe “P” was done after all other parts were done.)

Summary – Make sure to present the chief complaint with age and gender.

Narrow differential – Get 3 differential with reasoning for each.

Analyze differential – Explain why you think the main diagnosis is and why other diagnoses are not.

Plan management – Start from conservative measure to invasive.

Self-learning – This part is not very important but you need to be ready with some legitimate questions. This part somewhat overlaps with the second “P” (Probe). I asked something like “how would I really know which dx to treat in the real situation?”, “how can I distinguish very small differences between two different compelling dx?”, and etc.

Week 3/6 Case study – There are 2 parts for this assignment. My tip of advice on these case study assignments is to be very detailed. Follow the rubrics, word for word and nail every bit of rubric. I think I was blessed with the professor. I did get 50/50 for both Week 3 case study postings. I did follow exactly what the rubric stated. However, I have heard that many people didn’t get full credit not because they missed contents but not doing the APA references. I have seen people getting their points off down to 42 due to references. Yes, really. Make sure that you follow exactly how APA should be.

Part 1 Discussion

1. H&P findings and summary – A narrative form of the overall status of the pt.
2. DDx and patho – Come up with at least 3 ddx and list the S&S of each ddx. Then, either underline or bold the S&S that is presented by the pt. Make sure to put ICD-10 code for each ddx.
3. Analyze Dx – For each ddx, explain what ddx is and why you think one dx would apply to the pt or not as if you are doing a self discussion.
4. Rank ddx – List from most likely to least likely ddx. I just had 1 sentence or a table for this section.
5. Tests and rationals – List some of the diagnostic tests that would need in order for you to confirm the primary dx.

Yes, you will need to put references in APA format.

Your initial post has to be done by Tuesday of the week and you need to reply to 1x to peer and at least 1x to your instructor if he/she asks any question.

Part 2 Discussion

1. Primary dx – Simply discuss the primary diagnosis with S&S listed that the pt presented and any family hx.
2. Identify ICD-10 code – Just put the IDC-10 code
3. Treatment plan – Include medication, diagnostic tests, patient education, and referral. Make sure that each part is backed up with resource articles.
4. Active problem list – You will identify the presence of any active problems that the pt showed.
5. Any changes? – This part seemed very unnecessary to me as you will treat the pt with the best possible treatments. You would just have to come up with something that you can BS.
6. F/U plan – Similar to the Part 1 Discussion. Make sure to have references.

Your initial post has to be done by Tuesday of the week and you need to reply to 1x to peer and at least 1x to your instructor if he/she asks any question.

Week 4 – Midterm – Hum. I don’t want to scare you but I want you to be ready for this. It’s poorly written exam with typos and confusing wordings. I don’t think I ever had an exam with that many NOT questions (Which one of these are NOT the right answer). You know, until this exam, I never knew these NOT questions were more difficult than the other way around. I felt as if those NOT questions were semi-SATA (select all that apply) questions. Unless you know all other 3 right answers, you cannot get them right! Not to mention these questions were also nitpicking just like Week 1 exam. Did the exams follow the study guide? Well, I would have to say yes but the study guide is nothing but huge headlines of topics. No more, no less. I also did see some questions that were not part of the coverage. Yes, it does cover the 1st-week exam contents. At least those were less annoying than the actual 1st exam questions. There were a few true/false questions too.

How should you study? Just like the week 1 exam, know EVERYTHING in the lecture. There were some questions that were not covered by the lecture and came out. You may have to fight for that. Did questions come out from the Youtube video lectures? You bet! I heavily focused on the lecture scripts. If you have leftover time, then go after the textbook. I also used Hollier review book and Hollier Clinical Guidelines. Some of the lecture contents are almost exactly the same as the Hollier review book. Um… makes me wonder… =p

SNAPP assignment – This assignment is done over the phone just like the YouTube video that was in the Week 1 module (SNAPPS #1, #2). Your instructor will send you an email regarding the schedule of time. You will get to pick on what time/date you would like to do the presentation. The email will also have instructions. Your instructor will either let you pick your patient from the patients that you logged to the MyEvaluations or your instructor will pick for you. Some nicer instructors will let you pick ahead of time so that you are prepared. Some “not so good” instructors will pick just before the call.

During the call (lasts about 15~20 mins), you are going to present a patient that you saw during your clinic by using SNAPP. I prepared the presentation by writing out SNAPP form on Word program and almost literally read it (make sure to write as if you are just talking by mixing “and…, um…”). I did put the Probe part in the last part of the presentation and make sure to have a few legit questions.

I heard that some instructors asked very detailed questions. So be prepared with diagnosis, treatment plans and so on.

Tip for this assignment is to have MyEvaluations is done in detail. I literally have entire chart copy-pasted on the MyEvaluations without sensitive personal information.

Templates you will need.

1. SNAPPS Template for Oral Presentation (May2018)
2. SNAPPS Template for Written Assignment (May2018)

CPG (Clinical Practice Guideline) – This assignment can be very confusing. Again, follow the rubric in detail. By Week 4, you should have received email from your instructor with a topic and an article. If the topic that you received is something that you didn’t get to treat at the practicum, let your instructor know so that you can change your topic. In my case, I initially got the hyperlipidemia. I did have HTN pt but no one really comes to a clinic just for the hyperlipidemia. So, I changed the topic to something else. There are several parts to this assignment.

1. PPT – With your assigned disease, you will make a ppt that you will later present with Kaltura.
2. On Week 7: Clinical Practice Guideline Presentation (0 pts) section – you will post your recorded presentation and the article that you got from your instructor. Due by Wednesday of Week 7.
3. On Week 7: Clinical Practice Guideline Assignment (150 pts) section – you will post the narrated transcript of the presentation. Due by Wednesday of Week 7.
4. On Week 7: Clinical Practice Guideline Peer Review (50 pts) section – You will post your peer review. There is a template (NR511_Peer Reviewer Template (May2018)) for this. Make sure you have the right version as yours may differ from mine. Once you post the peer review, you also need to email it to the peer that you reviewed.

What is the use of the article that the instructor gave it to you? It supposed to be the treatment guideline for the diagnosis that you were assigned. The article should have several statements regarding the treatment. You will be picking up to 5 of them and present them. Some may have less than 5 statements. Make sure to find that the article that was given to you is most updated by searching google.

Final exam – Yes, you made it! Probably you want to know how to study for the final. Well, simple answer, know everything. I focused on the lecture scripts (I stopped watching the videos. Many of the just read straight off of the ppt without any explanation. No point of watching.) I also used Hollier review book and Hollier Clinical Guidelines.

Reflection – I don’t know what to say about this one. Just … all the way. -_-

Do not lose any points from assignments. Every point will be very crucial for you to keep the grade as high as you can. Midterm and final exam questions are quite random. Some of them are very detailed and some are stupidly easy. Any final exam is never designed to raise grade up! You need to keep your grade up as high as you can so that even if you fail your final exam, you can still pass the class. I was lucky enough to have all assignments with full credit and I needed no more than 50 points on the finals for me to pass the class.

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