NRNP 6634 Week 11 Reflection Example

Reflection: An Early Commitment to the First Plausible Diagnosis, Where It Showed, and the Practice That Replaced It

Student Name

College of Nursing, Walden University

NRNP 6634: Psychiatric Mental Health Advanced Practice Nursing Care of Adults and Older Adults

Instructor Name

Month Day, Year

Reflection: An Early Commitment to the First Plausible Diagnosis, Where It Showed, and the Practice That Replaced It

One Pattern, Claimed Early

Across the first half of this term, I committed to the first plausible diagnosis and wrote the alternatives thinly, as if they were there to be dismissed. The pattern is visible in three of my own submissions, all about the same composite woman of 72 with low mood and memory complaints after her sister's death.

Quoted Lines From My Submissions

Week 2, the interview write-up. My first draft's closing line read, "Presentation consistent with major depression." An interview write-up is supposed to record, not conclude, and I had concluded before the mental status examination or collateral history existed. I removed the line before submitting, but the draft shows where my attention had already settled.

Week 4, the discussion post. I opened with the answer, depression rather than a neurocognitive disorder, and supported it with the time course and collateral. That was the assignment's structure and I stand by the answer. But my first draft had no paragraph on what would overturn it; I added "The finding that would overturn it" only after rereading the prompt.

Week 5, the differential analysis. In my first draft, Alzheimer disease received three sentences and the word "unlikely." Medication effects were not a candidate at all; the diphenhydramine was in my own week 2 history and I had not connected it to her memory.

A Turning Point With a Cause

The shift came from written feedback on my week 4 post, which asked: "If her daughter had said the forgetting started last year, what would you do differently?" I could not answer quickly, and that told me my conclusion rested on one piece of collateral that I had not tested. After that feedback I read Croskerry's account of cognitive errors in diagnosis, which names premature closure, settling on a diagnosis before the evidence has confirmed it, as one of the errors clinicians make most often (Croskerry, 2003). I also read Byers and Yaffe's review, which describes late-life depression as possibly a prodrome of dementia, a consequence of it, or a risk factor for it (Byers & Yaffe, 2011). Together they showed me that my depression answer could be right and still leave the dementia question open, which is different from answering it.

Change, Written as Behavior

What I do now, in terms someone else could check. Every assessment I write names at least one finding that would overturn the leading diagnosis. Every differential gives each candidate the same three parts, for, against, and the settling finding, and includes at least one medication or substance candidate for any adult. A diagnosis I cannot settle is written as open, with the date and the test that will revisit it. In the week 7 treatment plan, the memory problem carries a repeat MoCA, a screen built to detect mild impairment (Nasreddine et al., 2005), and a stated referral trigger rather than an assumption that treating the depression will fix it; in the week 9 risk assessment, the triggers for review are written down. Those are the practices; the documents show whether I kept them.

What Did Not Change

Some things did not change, and saying so is part of an honest account. I still reach for a leading diagnosis quickly; the difference is that I now write down what would dislodge it, rather than pretending I have not already formed a view. I still find collateral history hard to obtain at the first visit, and my week 2 write-up recorded that gap rather than filling it; I have not solved the problem of getting fuller collateral early, only of recording its absence honestly. And I still write the patient's words more fluently than I write my own reasoning about them, which is why the reasoning paragraphs in my later submissions took the longest to draft.

The next test of this change will not be another composite case. It will be the first real patient whose presentation fits a pattern I recognize immediately, when writing the overturning finding will feel unnecessary. That is the moment the practice has to hold.

The Model Working Underneath

The model underneath this change is that a diagnosis is a hypothesis carried forward with its test attached, not a conclusion to defend. My first-half submissions treated the leading diagnosis as the destination and the alternatives as obstacles; my second-half submissions treat the leading diagnosis as the current best explanation and the alternatives as the questions that the next visit must ask. The patient's own words in week 8, declining testing until spring, tested that model in a way I had not expected: holding a question open respectfully sometimes means holding it open because she has chosen to, not only because the evidence requires it. That is the part I am still learning.

References

Byers, A. L., & Yaffe, K. (2011). Depression and risk of developing dementia. Nature Reviews Neurology, 7(6), 323-331. https://doi.org/10.1038/nrneurol.2011.60

Croskerry, P. (2003). The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine, 78(8), 775-780. https://doi.org/10.1097/00001888-200308000-00003

Nasreddine, Z. S., Phillips, N. A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I., Cummings, J. L., & Chertkow, H. (2005). The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society, 53(4), 695-699. https://doi.org/10.1111/j.1532-5415.2005.53221.x