Breaking Down the Differential Diagnosis for the New NP

Breaking Down the Differential Diagnosis for the New NP

Posted on March 24, 2021 | by Julie Scott | Leave a Comment

A differential diagnosis is a list of potential conditions a patient may have. Through my experience as an instructor, I have found that NP students often struggle with this difficult task. However, this is an incredibly important skill to master, as it is a foundation for providing excellent patient care. Adopting a systematic way of thinking can help organize an NP's thoughts.

Differential Diagnosis Challenges:

It is impossible to know every symptom for every single disease
The process can take a lot of time and research
Patients won't always be honest or tell the whole story
There is no "one size fits all" approach

Steps to Completing a Differential Diagnosis

Following these steps will help new NPs develop a comprehensive differential diagnosis.

1. Taking a Good History

The first step in conducting a differential diagnosis is completing and reviewing an accurate and thorough evaluation of a patient's medical, surgical, social, and family history. An accurate medication list is important as well. These areas often include details that will be helpful to refer to later on.

2. Physical Exam

A great deal of information about a patient can be discovered without using a stethoscope. Watching posture, breathing, and other behaviors can provide a wealth of information. While a meticulous physical exam is critical, never discount the non-verbal clues displayed by the patient.

3. Diagnostics

A thorough review of a patient's available labs and diagnostic imaging is another important aspect. Tests will often definitively result in a diagnosis, but not always. In these cases, combining diagnostic results with the physical exam findings and patient history will be necessary for the diagnosis. Sometimes, testing will need to be ordered. Beginning to think about potential conditions can help determine which types of tests may lead to a diagnosis.

4. Thinking Process

Compiling a patient's history, physical exam, and diagnostic test findings requires the ability to synthesize the information. This is a skill that will not be learned immediately, but will instead develop over time.

An Experienced NP's Process

Here are the steps I take when developing a differential diagnosis. At this point in my career, I am able to do this in my head without writing it down. However, I would advise new NPs to take notes, as information can be overwhelming when clicking through charts.

Review

Review the patient chart (if available) and chief complaint of the visit before the patient arrives. Here, I can start to develop a potential list of causes for their symptoms. It is important to not let any bias cloud judgment, as keeping an open eye and mind is critical

Confirm

During the visit, confirm the patient's full and accurate history and perform a physical exam.

Data

Review any previous imaging or laboratory data that may be relevant to the patient's current presentation.

Question

Ask the patient many questions and most importantly, listen to their answers! Using the OLDCARTS system works best for me (Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity).

Think

During the above steps, I will be going through a list of possible causes based on experiences with past patients. I also draw on what I have learned or read previously over the years. The main question I keep asking is "what could this be?"

System-based thinking is a helpful way to organize my thoughts. For example, if shortness of breath is a presenting symptom, I would think of all potential causes and compare them with the patient's exam findings and history to arrive at a list of differentials. Once I have a few differential diagnoses, I will review them, determine what fits best at the moment, and treat them appropriately. I include a list of the differentials in my documentation for easy reference by myself or another provider who may see the patient in the future.

Keep in mind that common diagnoses are frequent, and not every patient will have a rare illness that nobody has ever seen before. It does happen occasionally though!

Follow Up

Shortly after providing a diagnosis, I follow up with the patient to make sure there has been a resolution of their symptoms. If not, I begin looking into other causes.

Collaborate

If I don't know the answer or am unsure of what to do, I collaborate with another provider and ask questions. It is absolutely OK to not have all of the answers, and transparency with the patient is important. Letting a patient know that I don't have the answer but will do my best to find it will help put them at ease.

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The process reviewed above is just one way to develop a differential diagnosis. As the new NP settles into practice, they will determine what works best for them. While obtaining a differential diagnosis is a critical skill for NPs, it will take time to fully master. Therefore, never hesitate to ask for support or collaborate with another provider. With enough time and experience, this will become much easier to accomplish.

What I Wish I Had Known as a New NP

Posted on March 6, 2021 | by Julie Scott | Leave a Comment

From excitement and elation to fear and anxiety, a brand new nurse practitioner (NP) is likely to experience a wide range of emotions. Transitioning from the role of a seasoned nurse to a novice NP can be particularly stress-inducing. Although the past few years of formal schooling and practicum experiences have certainly been valuable, there is no handbook for handling this transition. When I graduated from NP school, I thought I had to know it all. (Spoiler alert—you don't!) From taking board certification exams to landing a job and establishing a new career, here are some of the things that I wish I had known when first starting out as a new NP.

Board Certification

The two certifying bodies for NPs are the American Association of Nurse Practitioners (AANP) and the American Nurses Credentialing Center (ANCC). New graduates often wonder if taking a review course for the board certification exam is worth it, as this adds another expense to the already costly process of becoming an NP. In my opinion, a review course is worth every penny. It helped me better organize my study materials, effectively prioritize the most important information, and develop a framework to prepare for the exam. I haven't met one NP who did not find an exam review course to be beneficial.

The Job Hunt

In some cases, practicum experiences in NP school can lead to a job upon graduation. However, this is not always the case. The new NP should start searching for a job when they are comfortable doing so. However, it's important to keep in mind that the process will likely take much longer than applying for and securing a new RN job. Some NPs aim to have a job waiting for them prior to graduation, while others prefer waiting until passing board exams to begin the search. The new NP should have an updated resume that suits their desired job and it should be tailored to each position they apply to. Many resources exist for support with resume writing, and these can be highly valuable tools for the new NP.

Role Transition

Working as an NP involves a different set of tasks and skills than an RN role. However, the critical thinking skills developed while practicing as an RN will serve as a foundation for future NPs. These new skills will continue to build and advance—even many years into practice. Particularly when working in the same location, the line from RN to NP can be a tough one to cross. It can be challenging for others to see you take a new role with different expectations. Give yourself the grace to acknowledge that it's okay to not know everything and gaining confidence in this new position will take time.

Ask Questions

It's normal to have many questions as a new NP. Never be afraid to ask them, as this is how learning continues after graduation. Particularly during COVID times, practicum experiences may have had limited clinical opportunities. When starting out, a new NP will have unfamiliar experiences or situations daily. Understanding everything from the very beginning should never be expected.

Find Resources

Whether working in primary care or a specialty, a variety of invaluable resources are available for NPs to refer to. As a medical oncology NP, UpToDate and the National Comprehensive Cancer Network (NCCN) are resources that I continue to use daily— even 10 years into my career. Finding the most useful tools and bookmarking them for future reference will make practice much easier. As time goes on, a great deal of information will be committed to memory.

Collaboration

Serving as a crucial piece of providing excellent patient care, collaboration lies at the heart of the NP role. This includes teaming up with patients, RNs, and other staff members. In addition, the relationship with the collaborating physician should be strong. While some states offer full independent practice opportunities for NPs, many require some level of collaboration with a physician. The new NP needs to work alongside someone that they feel comfortable with and can turn to with questions without feeling judged. Furthermore, the NP should believe that the collaborating physician does a good job in their role. There may be a period of time where the new NP feels that they have to earn their trust and prove themselves. However, the physician also needs to earn the trust of the NP. Having a poor relationship with a collaborating provider can lead to significant job dissatisfaction. Even if working completely independently, establishing a strong dynamic with a more experienced healthcare provider can be invaluable.

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All experienced NPs will be able to recall some things that they wish they knew when first starting out. It's important for new NPs to remember that they will never be expected to know everything immediately and should embrace opportunities to work in positive environments that promote ongoing collaboration. Additionally, keep in mind that the first job after graduation may not be a perfect position. However, it will certainly offer much to learn from.