Case: 1:
Chief Complaint: “Pain in Right Side” A 40-year-old man presents to his primary care provider (PCP) with right upper quadrant (RUQ) pain for 2 days. The pain is described as “sore” and rated 4 on 1 to 10 pain scale. The pain is intermittent and not worsening. He reports food does not seem to make it better or worse. No nausea or vomiting or diarrhea or constipation are reported.
Vital signs: heart rate, 75; blood pressure, 122/78; respiration rate, 15; afebrile.
Examination: No acute distress. Abdomen: mildly tender on palpation at RUQ; no masses, hepatomegaly or splenomegaly.
Diagnosis: Gallbladder disease.
Plan: Abdominal ultrasound with reflexive cholescintigraphy (hepatobiliary iminodiacetic acid) scan within 1 week. Patient instructed to call provider if worsening symptoms occur. He is also told to avoid any fatty foods or alcohol consumption. The patient is agreeable to plan.
Follow-up: Two days after the initial visit, the patient calls his PCP with worsening RUQ pain. Ultrasound imaging was scheduled for later that day. Patient then started having shortness of breath while at home and went to the local emergency department (ED). Computed tomography angiography of the chest revealed a right-sided pulmonary embolism. Patient did not have any family history of clotting disorders and no recent surgery, immobilization, or travel. Patient had been on testosterone injections for several years for low testosterone levels, and this was not updated in his medical record at his PC
Case 2
Chief Complaint: “Fever and Sleepy” A 3-year-old girl presents with her mother to a walk-in clinic with fever, nasal drainage, and fatigue for 2 days. She was observed hiding her head in her mother’s chest during the examination.
The presentation occurred during flu season. The clinician had 6 positive flu tests that day, all with similar symptoms, but most included a cough.
Vital signs: heart rate, 125; respiration rate, 20; blood pressure, 100/72; temperature, 100.8F.
Examination: Lungs clear, heart rate regular, no murmur. Head, eyes, ears, nose, and throat: normocephalic, conjunctivae clear, tympanic membrane without bulging or redness, pharynx normal, nares normal with clear drainage, tonsils 1þ, no erythema or exudate. The patient did not want to look at the clinician in a brightly lit room. The patient was lethargic and had limited tearing when crying. Rapid flu test: Negative.
Diagnosis: Presumptive seasonal influenza.
Plan: Supportive care, including encouraging fluids, Over-the-counter acetaminophen for fever, and age-appropriate antiviral medication for the flu was prescribed.
Follow-up: Parents were unable to keep her fever down over the next 1 day, and she progressively became more lethargic. The patient was taken to the ED, and a diagnosis of viral meningitis and dehydration was made. The patient spent several days in the hospital but did completely recover.
Describe the Dual Process Theory and Reasoning Process and how it applies to making decisions for the advanced practice nurse.
What are cognitive dispositions to respond? How are these applied in the APN setting?
Describe cognitive debiasing.
Describe how Type 1 (System 1) and Type 2 (System 2) processes and strategies can be applied to each case to help the NP make decisions and to decrease potential diagnostic errors.
What considerations for change to practice should the NP consider in each situation as a way to decrease the chance of future diagnostic and care decisions?