NGR 6001 Deliverable 2 Differential Diagnoses Interview Preparation

NGR 6001 Deliverable 2 Differential Diagnoses Interview Preparation

Student Name

Rasmussen University

NGR6001

Instructor Name

Date

Diagnostic Reasoning Case Notes

During my time as a registered nurse, I made a great impression on my perception of clinical assessment and diagnostic reasoning. The patient was a 52-year-old man who came to the emergency department complaining of a sudden shortness of breath, pleuritic chest pain, and mild hypoxia. He was two days back from an overseas trip and stated that he had no serious medical history other than mild hypertension.

At first, his symptoms aroused a suspicion of an infection of the respiratory tract or something aching in the bones, but with a careful look at the symptoms, including the fact that he had traveled recently, tachycardia, and the absence of lung sounds, I decided to look beyond the surface run of the symptoms. This case subsequently turned out to be pulmonary embolism (PE), which largely influenced my patient evaluation process. When I am getting ready to work as a Family Nurse Practitioner (FNP), having this case in mind, I could think about the ways in which my diagnostic reasoning and clinical decision-making would be different now.

Case Details and Diagnostic Reasoning Inputs

The main factors that provoked my initial concern were the presenting symptoms of the patient, consisting of acute dyspnea, chest pain that was worsened by deep breathing, and oxygen saturation that varied between 88% and 92%. His pulse was 112 bpm, his blood pressure was normal, and his respiratory rate was somewhat increased. No fever, cough, sputum, and lung auscultation showed no wheezing, no crackles.

The initial lab results did not indicate infection, and his chest X-ray did not have infiltrates (Deng et al., 2024). These results played an essential role in the differentiation diagnosis that comprised pulmonary embolism, pneumonia, pneumothorax, acute coronary syndrome, and exacerbation of chronic obstructive pulmonary disease (COPD). Being a nurse, I understood what an urgent situation needed and immediately increased the level of care, delivering the patient with additional oxygen, cardiac assessment, and immediate physician consultations.

In this instance, my diagnostic thinking started with the analysis of the available information, the identification of risk factors (prolonged immobility as a result of recent traveling), and the identification of discrepancies between the symptoms and preliminary results. Absence of infection signs, no pulmonary congestion, and pleuritic pain left the opportunities limited, making pulmonary embolism at the top of the differential list (Hasan Veysel Keskin et al., 2025).

Nurse versus FNP Approach

My work as a registered nurse was engaged in the timely recognition, stabilization, and communication. I obtained history, observed vital signs, secured IV access, and supported the use of fast diagnostic tests. Nevertheless, as a Family Nurse Practitioner, I would do things differently (Vrettou et al., 2024). My independent assessment of the patient would be based on clinical decision-making instruments, like the Wells Criteria of Pulmonary Embolism, to determine pre-test probability. According to such an evaluation, I would order D-dimer in case the probability were low and intermediate, and CT pulmonary angiography (CTPA) in case the probability were large or when the result of the D-dimer test was positive.

Being an RN, I could only make observations and report my findings, but as an FNP, I would assume a more independent role, as I would initiate orders, interpret test results, and create a treatment plan (Thomas et al., 2024). As an example, I would also begin anticoagulation treatment based on clinical practices, evaluate the risk of bleeding, and decide whether to treat the patient in an inpatient or outpatient setting after confirming PE by using CTPA. I would also offer mobility and hydration/follow-up counseling to avoid recurrence, which exceeds the scope of the RN but is indicative of the advanced practice aspect of the FNP.

Diagnostic Reasoning and Differential Narrowing

Diagnostic reasoning is a logical sequence comprising assessment, generation of a hypothesis, and confirmation. To start with, the symptoms of the patient were general to accommodate multiple disorders (Tang et al., 2023). Nonetheless, certain indicators pleuritic pain, tachycardia, hypoxia, and recent travel, were most indicative of a thromboembolic occurrence. In this instance, evidence-based practice dictates the assessment of a D-dimer test to rule out or confirm the diagnosis. A positive D-dimer would be an indication of CTPA, which would be used to visualize emboli in the pulmonary vasculature.

This step-by-step method is justified by evidence from the NICE (NG158) and ESC 2019 guidelines in order to make an early diagnosis and treatment. In case the CTPA confirms the presence of pulmonary embolism, the immediate start of anticoagulant therapy (including low molecular weight heparin or direct oral anticoagulant) is required. Conversely, in case of a negative imaging, other diagnoses such as pneumonia or musculoskeletal pain would be re-evaluated (Santus et al., 2023). This methodical elimination of the differential diagnosis is indicative of the critical thinking and evidence-based reasoning that constitute advanced nursing practice.

Treatment Plan as an FNP

As an FNP, my first steps to pulmonary embolism would include starting anticoagulation therapy, observing bleeding complications, and assessing the suitability of the patient to receive outpatient care due to his/her stability and comorbidities. Education of the patient would also make a difference- discussing the adherence to medication, the identification of warning signs, and changing the risk factors, including prolonged immobility or dehydration (Hasan Veysel Keskin et al., 2025).

It would be coordinated with specialists and followed up with imaging in case of necessity to make sure that the care is complete. This increased scope will enable me to shift my role as a facilitator of care to a provider of diagnosis and care, unlike when I was a registered nurse.

Conclusion

The case served as one of the illustrative cases that enhanced my knowledge of clinical assessment and diagnostic reasoning. My role as a nurse played a significant part in early recognition and communication, whereas as a Family Nurse Practitioner, I will be able to implement evidence-based instruments, carry out the interpretation of diagnostic results, and start treatment on my own.

This development can be described as the essence of advanced practice nursing, the ability to provide people with compassionate bedside care and, at the same time, make relevant clinical decisions independently.

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References for NGR 6001 Deliverable 2 

Deng, Y., Lai, J., & He, Q. (2024). Pulmonary thromboembolism: a case report and misdiagnosis analysis of a 63-year-old female patient. Frontiers in Medicine, 11(1), 1411338. https://doi.org/10.3389/fmed.2024.1411338

Hasan Veysel Keskin, Neslihan Ozcelik, Elvan Senturk Topaloglu, Songul Ozyurt, Aziz Gumus, & Sahin, U. (2025). The Wells Score, the Revised Geneva Score, or the Padua Score? Life, 15(7), 1115–1115. https://doi.org/10.3390/life15071115

Santus, P., Radovanovic, D., Saad, M., Zilianti, C., Coppola, S., Chiumello, D., & Pecchiari, M. (2023). Acute dyspnea in the emergency department: a clinical review. Internal and Emergency Medicine, 18(5), 1491–1507. https://doi.org/10.1007/s11739-023-03322-8

Tang, L. J., Hu, Y., Dong, P., Yang, C., Tang, C., Huang, Y., Gu, J., Min, M., Lin, X., & Tong, C. (2023). PECSS: Pulmonary Embolism Comprehensive Screening Score to safely rule out pulmonary embolism among suspected patients presenting to the emergency department. BMC Pulmonary Medicine, 23(1), 287. https://doi.org/10.1186/s12890-023-02580-8

Thomas, S. E., Weinberg, I., Schainfeld, R. M., Rosenfield, K., & Parmar, G. M. (2024). Diagnosis of Pulmonary Embolism: A Review of Evidence-Based Approaches. Journal of Clinical Medicine, 13(13), 3722. https://doi.org/10.3390/jcm13133722

Vrettou, C. S., Dima, E., & Sigala, I. (2024). Pulmonary Embolism in Critically Ill Patients—Prevention, Diagnosis, and Management. Diagnostics, 14(19), 2208–2208. https://doi.org/10.3390/diagnostics14192208

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