NR569 Differential Diagnosis in Acute Care Midterm
1. Comprehensive - Appropriate for new patients in the office or hospital.
Patient - Provides fundamental and personalized knowledge about patient.
Assessment - Strengthens the clinician-patient relationship.
- Helps identify or rule out physical causes related to patient concerns.
- Provides a baseline for future assessments.
- Creates a platform for health promotion through education and counseling.
- Develops proficiency in the skills of physical assessment.
2. Focused Patient - Appropriate for established patients, especially during routine or urgent care
Assessment visits.
- Addresses focused concerns or symptoms.
- Assesses symptoms restricted to a specific body system.
- Applies examination methods relevant to assessing the concern or problem as
thoroughly and carefully as possible.
3. Subjective Infor- - The clinical record from the Chief Complaint (CC) through the Review of Systems
mation (ROS) is considered SUBJECTIVE information.
- Includes symptoms which are health concerns the patient tells the provider.
- Includes feelings, perceptions, and concerns obtained from the clinical interview.
- Examples: complaints of sore throat, headache, or pain.
4. Objective Infor- - All physical examination, laboratory information and test data are objective data.
mation
5. Components of - Initial information (Identifying patient information/source/reliability)
Comprehensive - Chief Complaint(s)
Adult Health - History of Present Illness
History - Past Medical History
- Family History
- Personal/Social History
- Review of Systems (ROS)
6. SNAPPS method
, NR569 Differential Diagnosis in Acute Care Midterm
- Summarize the history and findings.
- Narrow the differential diagnosis to two to three possibilities.
- Analyze the differential by comparing and contrasting the possibilities.
- Probe the preceptor by asking questions about alternative approaches or uncer-
tainties.
- Plan the management of the patient's health issues.
- Select an issue from the case for self-directed learning.
7. Creating a Differ- - The differential diagnosis process involves using clinical reasoning to distinguish
ential Diagnosis between two or more conditions that share similar signs and symptoms. Based
*Hoofbeats = on the CC the NP gathers information through PMH (subjective data) and physical
Horses NOT Ze- examination (objective data) to establish a broad list of common & uncommon
bras* diagnosis. As the provider collects more data, competing hypotheses are either
confirmed, disproved, or their priority changes.
8. Steps for Creat- 1. Initially start with a broad list of diagnoses until further information or data is
ing a Differential obtained.
Diagnosis
2. List your top diagnosis FIRST followed by other potential diagnoses for a specific
problem *but keep it problem oriented until you have an actual diagnosis.*
3. Aggressively prioritize work up of the most likely and most harmful (ie, life
threatening) diagnoses under consideration.
4. Prioritize the work up of ACUTE and REVERSIBLE diseases followed by CHRONIC
and IRREVERSIBLE (eg, delirium r/t a medical cause vs. chronic, progressive de-
mentia).
5. As information or data that effectively rules out a particular diagnosis for a chief
complaint becomes available, remove that diagnosis from your list & focus your
attention on remaining possibilities.
, NR569 Differential Diagnosis in Acute Care Midterm
6. Once a diagnosis has been confirmed, the problem list should be diagnosis-ori-
ented rather than problem-oriented.
9. Pertinent Positive - Symptoms or signs that are present that you would expect to find if a possible
cause for for a patient's problem were true, which then supports the diagnosis.
10. Pertinent Nega- Expected symptoms or signs that are not present, facts that you would expect to
tive find if a possible cause for a patient's problem were true, which then weaken this
diagnosis by their absence.
11. Principles of 1. Is the organization clear?
Good Documen- - Make the headings clear.
tation - Accent your organization with indentations and spacing.
**Checklist to En- - Arrange the HPI in chronologic order, starting with the current episode, the filling
sure a Quality in relevant background information.
Clinical Record.**
2. Does the included information contribute directly to the Assessment?
- Spell out the supporting evidence, both positive and negative, or each problem or
diagnosis. Make sure there is sufficient detail to support your differential diagnosis
and plan.
3. Are pertinent negatives specifically described?
- Often portions of the history or examination suggest that an abnormality might
exist or develop in that area. For example, for the pt with notable bruises, record the
"pertinent negatives", such as the absence of injury or violence, familial bleeding
disorders, or medications/nutritional deficits that might lead to bruising.
4. Are there overgeneralizations or omissions of important data?
- REMEMBER THAT ANY INFORMATION NOT RECORDED IS INFORMATION LOST.
6. Is there too much detail?
- Is there excess information or redundancy? Make your descriptions concise. You
can omit unimportant structures even though you examined them, such as normal
1. Comprehensive - Appropriate for new patients in the office or hospital.
Patient - Provides fundamental and personalized knowledge about patient.
Assessment - Strengthens the clinician-patient relationship.
- Helps identify or rule out physical causes related to patient concerns.
- Provides a baseline for future assessments.
- Creates a platform for health promotion through education and counseling.
- Develops proficiency in the skills of physical assessment.
2. Focused Patient - Appropriate for established patients, especially during routine or urgent care
Assessment visits.
- Addresses focused concerns or symptoms.
- Assesses symptoms restricted to a specific body system.
- Applies examination methods relevant to assessing the concern or problem as
thoroughly and carefully as possible.
3. Subjective Infor- - The clinical record from the Chief Complaint (CC) through the Review of Systems
mation (ROS) is considered SUBJECTIVE information.
- Includes symptoms which are health concerns the patient tells the provider.
- Includes feelings, perceptions, and concerns obtained from the clinical interview.
- Examples: complaints of sore throat, headache, or pain.
4. Objective Infor- - All physical examination, laboratory information and test data are objective data.
mation
5. Components of - Initial information (Identifying patient information/source/reliability)
Comprehensive - Chief Complaint(s)
Adult Health - History of Present Illness
History - Past Medical History
- Family History
- Personal/Social History
- Review of Systems (ROS)
6. SNAPPS method
, NR569 Differential Diagnosis in Acute Care Midterm
- Summarize the history and findings.
- Narrow the differential diagnosis to two to three possibilities.
- Analyze the differential by comparing and contrasting the possibilities.
- Probe the preceptor by asking questions about alternative approaches or uncer-
tainties.
- Plan the management of the patient's health issues.
- Select an issue from the case for self-directed learning.
7. Creating a Differ- - The differential diagnosis process involves using clinical reasoning to distinguish
ential Diagnosis between two or more conditions that share similar signs and symptoms. Based
*Hoofbeats = on the CC the NP gathers information through PMH (subjective data) and physical
Horses NOT Ze- examination (objective data) to establish a broad list of common & uncommon
bras* diagnosis. As the provider collects more data, competing hypotheses are either
confirmed, disproved, or their priority changes.
8. Steps for Creat- 1. Initially start with a broad list of diagnoses until further information or data is
ing a Differential obtained.
Diagnosis
2. List your top diagnosis FIRST followed by other potential diagnoses for a specific
problem *but keep it problem oriented until you have an actual diagnosis.*
3. Aggressively prioritize work up of the most likely and most harmful (ie, life
threatening) diagnoses under consideration.
4. Prioritize the work up of ACUTE and REVERSIBLE diseases followed by CHRONIC
and IRREVERSIBLE (eg, delirium r/t a medical cause vs. chronic, progressive de-
mentia).
5. As information or data that effectively rules out a particular diagnosis for a chief
complaint becomes available, remove that diagnosis from your list & focus your
attention on remaining possibilities.
, NR569 Differential Diagnosis in Acute Care Midterm
6. Once a diagnosis has been confirmed, the problem list should be diagnosis-ori-
ented rather than problem-oriented.
9. Pertinent Positive - Symptoms or signs that are present that you would expect to find if a possible
cause for for a patient's problem were true, which then supports the diagnosis.
10. Pertinent Nega- Expected symptoms or signs that are not present, facts that you would expect to
tive find if a possible cause for a patient's problem were true, which then weaken this
diagnosis by their absence.
11. Principles of 1. Is the organization clear?
Good Documen- - Make the headings clear.
tation - Accent your organization with indentations and spacing.
**Checklist to En- - Arrange the HPI in chronologic order, starting with the current episode, the filling
sure a Quality in relevant background information.
Clinical Record.**
2. Does the included information contribute directly to the Assessment?
- Spell out the supporting evidence, both positive and negative, or each problem or
diagnosis. Make sure there is sufficient detail to support your differential diagnosis
and plan.
3. Are pertinent negatives specifically described?
- Often portions of the history or examination suggest that an abnormality might
exist or develop in that area. For example, for the pt with notable bruises, record the
"pertinent negatives", such as the absence of injury or violence, familial bleeding
disorders, or medications/nutritional deficits that might lead to bruising.
4. Are there overgeneralizations or omissions of important data?
- REMEMBER THAT ANY INFORMATION NOT RECORDED IS INFORMATION LOST.
6. Is there too much detail?
- Is there excess information or redundancy? Make your descriptions concise. You
can omit unimportant structures even though you examined them, such as normal
