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Gallbladder disease.

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 into her mother’s chest during the examination.

Presentation occurred during flu season. The clinician had 6 positive flu tests that day, all with similar symptoms, but most including 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. 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. Patient was taken to the ED, and a diagnosis of viral meningitis and dehydration was made. 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 error?
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.

Full Answer Section

Reasoning Process The Reasoning Process is a model of how people make decisions that is based on the Dual Process Theory. The Reasoning Process has four steps:

Problem Identification: The first step is to identify the problem that needs to be solved.
Information Gathering: The second step is to gather information that is relevant to the problem.
Generating Solutions: The third step is to generate possible solutions to the problem.
Evaluating Solutions: The fourth step is to evaluate the possible solutions and select the best one.

How the Dual Process Theory and Reasoning Process Apply to Advanced Practice Nursing The Dual Process Theory and Reasoning Process can be applied to advanced practice nursing in a number of ways. For example, advanced practice nurses can use the Dual Process Theory to understand how their own cognitive biases might influence their decision-making. They can also use the Reasoning Process to help them make more informed and evidence-based decisions about patient care. In the case of the 40-year-old man with RUQ pain, the advanced practice nurse might use the Dual Process Theory to identify any cognitive biases that might be influencing their decision-making. For example, the nurse might be biased towards diagnosing the patient with gallbladder disease because that is the most common cause of RUQ pain. However, the nurse should also consider the possibility that the patient's symptoms are actually caused by something else, such as a pulmonary embolism. The nurse can also use the Reasoning Process to help them make a more informed decision about the patient's care. The nurse should gather all of the relevant information, such as the patient's medical history, their symptoms, and the results of their physical examination. The nurse should then generate a list of possible diagnoses and evaluate each diagnosis based on the evidence. Finally, the nurse should select the diagnosis that they believe is the most likely and make a plan for the patient's care. In the case of the 3-year-old girl with fever, nasal drainage, and fatigue, the advanced practice nurse might use the Dual Process Theory to identify any cognitive biases that might be influencing their decision-making. For example, the nurse might be biased towards diagnosing the patient with the flu because that is the most common diagnosis during flu season. However, the nurse should also consider the possibility that the patient's symptoms are actually caused by something else, such as viral meningitis. The nurse can also use the Reasoning Process to help them make a more informed decision about the patient's care. The nurse should gather all of the relevant information, such as the patient's medical history, their symptoms, and the results of their physical examination. The nurse should then generate a list of possible diagnoses and evaluate each diagnosis based on the evidence. Finally, the nurse should select the diagnosis that they believe is the most likely and make a plan for the patient's care. The Dual Process Theory and Reasoning Process are important tools that advanced practice nurses can use to make more informed and evidence-based decisions about patient care. By understanding how these two models work, advanced practice nurses can improve their clinical judgment and provide better care for their patients.

Sample Answer

Dual Process Theory The Dual Process Theory is a model of human cognition that proposes that there are two distinct systems that are involved in decision-making: System 1 and System 2.

System 1: System 1 is a fast, intuitive, and effortless system that is responsible for making quick decisions based on heuristics and biases.
System 2: System 2 is a slower, more deliberate, and effortful system that is responsible for making more complex decisions that require careful reasoning.