NUR 560 Module 9 Final Project Example

Final Project: Tired and Thinner, From a Broad Differential to One Diagnosis in a 52-Year-Old Man

[Student Name]

Southern New Hampshire University

NUR 560: Advanced Health Assessment and Clinical Reasoning

Final Project

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Final Project: Tired and Thinner, From a Broad Differential to One Diagnosis in a 52-Year-Old Man

Fatigue and unintended weight loss are among the hardest presentations in primary care because they belong to no single organ system. The list of possible causes is long, runs from depression to cancer and cannot all be tested at once. The skill this course has built toward is the ability to gather complete data, organize it into a problem representation, generate a broad differential and then narrow it efficiently. This final project applies that process to a composite 52-year-old man. It argues that a structured history and examination, a limited first round of tests chosen to split the differential, and careful interpretation of one abnormal result led to a timely diagnosis that a vaguer approach could have missed.

History of Present Illness

He reports four months of tiredness that has worsened steadily. He now needs to rest after climbing one flight of stairs, which he could do easily last year. His weight has fallen from 88 to 81 kg, about 8% of his body weight, without any change in diet or exercise. Over the past two months he has opened his bowels two or three times daily instead of once, with softer stools. He has noticed neither red blood nor tarry, dark stools and has no abdominal pain, heartburn or trouble swallowing. He denies fever, night sweats, cough, heat intolerance, tremor, excessive thirst or urination.

Quantifying the weight loss mattered. Clinicians usually treat an unplanned drop of over 5% within 6 to 12 months as significant, and he lost 8% in only four.

Past, Family and Social History and Review of Systems

He has mild hypertension treated with amlodipine and uses ibuprofen for an aching lower back on most weekends and some weekdays. No colonoscopy or stool test has ever been done. His father had a heart attack at 70; there is no family history of cancer or inflammatory bowel disease. He is a warehouse supervisor, has never smoked, drinks about six drinks a week and has had one sexual partner, his wife, for 25 years. He has not traveled outside the country or had contact with tuberculosis. On screening, he reports normal mood and interest in activities. The review of systems is otherwise negative, including sleep, snoring, joint pain, rashes and urinary symptoms.

Physical Examination

Blood pressure is 128/78 mm Hg, heart rate 96, respiratory rate 16, temperature 36.8°C and oxygen saturation 98%. Body mass index is 25.8. He looks tired but not unwell. The conjunctivae and palms are pale. There is no jaundice, lymphadenopathy, thyroid enlargement or oral ulceration. Heart sounds are normal apart from a soft systolic flow murmur; the lungs are clear. The abdomen is soft and nontender, with no mass, enlarged liver or spleen. A rectal examination shows brown stool and no mass. There is no edema, rash or joint swelling.

Problem List and Opening Differential

The problem list is fatigue with reduced exercise tolerance, 8% unintended weight loss, a change in bowel habit, pallor with a flow murmur, regular NSAID use and no previous colorectal screening.

The opening differential was deliberately broad. Cancer came first because unexpected weight loss in primary care is a recognized predictor of cancer, particularly in older men, and is linked to several cancer types including colorectal cancer (Nicholson et al., 2018). Endocrine causes included hyperthyroidism and diabetes. Gastrointestinal causes included celiac disease, inflammatory bowel disease and peptic ulcer disease. Infections included HIV and tuberculosis. Depression, which commonly causes both fatigue and weight loss, and adrenal insufficiency completed the list. The pallor and change in bowel habit already tilted the probabilities toward a gastrointestinal source, but none of these could be excluded from the history and examination alone.

Choosing the First Tests

The first round of tests was chosen to split the differential rather than to confirm a favorite. A complete blood count with indices would detect anemia and suggest its type. Ferritin would identify iron deficiency. A metabolic panel, glucose and hemoglobin A1c would address diabetes, kidney and liver disease. Thyroid-stimulating hormone would address hyperthyroidism. Tissue transglutaminase IgA would screen for celiac disease, and HIV testing was offered. More invasive or costly tests, such as imaging, were held until the first results showed where to look.

Results and the Revised Problem Representation

The blood count showed hemoglobin 9.8 g/dL and small red cells, MCV 72 fL; ferritin was 8 ng/mL. White cells, platelets, kidney and liver function, glucose, hemoglobin A1c and thyroid-stimulating hormone were normal. Celiac serology and HIV testing were negative.

Revised problem representation: a 52-year-old man, never screened for colorectal cancer, with four months of fatigue, 8% unintended weight loss and looser stools who has a microcytic anemia with very low ferritin, consistent with iron deficiency.

In a man, iron deficiency anemia almost always signals blood loss, usually from the gastrointestinal tract, and must be explained. The gastroenterology guideline on iron deficiency anemia recommends a ferritin cutoff of 45 ng/mL rather than 15 ng/mL to diagnose iron deficiency and advises examining both the upper and lower gastrointestinal tract in men and postmenopausal women with iron deficiency anemia (Ko et al., 2020).

Ranked Differential After Testing

1. Colorectal cancer, most likely right-sided. For: age, no previous screening, weight loss, change in bowel habit, iron deficiency without visible bleeding, which is typical of slow blood loss from the right colon. Against: no palpable mass, a normal rectal examination.

2. Peptic ulcer or NSAID-related injury of the upper gut. For: regular ibuprofen. Against: no dyspepsia or black stools, and weight loss is less expected.

3. Upper gastrointestinal cancer. For: weight loss, anemia. Against: no trouble swallowing, pain or early fullness.

4. Inflammatory bowel disease. For: looser stools, anemia, weight loss. Against: no pain, blood, fever or family history, and onset at 52 is less typical.

5. Celiac disease. Against: negative serology on a normal diet.

Hyperthyroidism, diabetes, HIV and depression were now much less likely because of normal results and negative screens.

Diagnostic Plan and Outcome

He was referred urgently for colonoscopy and upper endoscopy, the ibuprofen was stopped and oral iron was started while he waited. Upper endoscopy was normal apart from mild gastritis. Colonoscopy found an ulcerated mass in the ascending colon, and biopsy confirmed adenocarcinoma. He was referred for staging imaging and to a colorectal surgeon.

At 52 he was seven years past the age at which current national guidance recommends that average-risk adults begin colorectal cancer screening (US Preventive Services Task Force, 2021). Had screening been done, a precancerous polyp might have been found years earlier.

Reflection on the Reasoning

Three points in this case could have delayed the diagnosis. The first was accepting fatigue as a result of work or age without quantifying his weight loss. The second was treating the anemia with iron alone, which would have corrected the blood count while the cancer grew. The third was attributing the iron deficiency to ibuprofen and examining only the upper gut. Guarding against each depended on a habit this course has emphasized: every abnormal finding needs an explanation, and a plausible explanation is not the same as a confirmed one. Organizing the case as a problem list, rewriting the problem representation after each set of results and ranking the differential with explicit reasons kept the reasoning honest and visible.

Conclusion

This project followed a man with two vague symptoms from a broad differential to a specific diagnosis. A complete history and examination produced a problem list; a limited set of first tests split the differential; and one abnormal result, iron deficiency in a man, was pursued rather than simply treated. The case shows why complete data, a problem representation that is revised as evidence accumulates and a ranked differential with stated reasons are the core tools of advanced assessment.

References

Ko, C. W., Siddique, S. M., Patel, A., Harris, A., Sultan, S., Altayar, O., & Falck-Ytter, Y. (2020). AGA clinical practice guidelines on the gastrointestinal evaluation of iron deficiency anemia. Gastroenterology, 159(3), 1085-1094. https://doi.org/10.1053/j.gastro.2020.06.046

Nicholson, B. D., Hamilton, W., O'Sullivan, J., Aveyard, P., & Hobbs, F. D. R. (2018). Weight loss as a predictor of cancer in primary care: A systematic review and meta-analysis. British Journal of General Practice, 68(670), e311-e322. https://doi.org/10.3399/bjgp18X695801

US Preventive Services Task Force. (2021). Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA, 325(19), 1965-1977. https://doi.org/10.1001/jama.2021.6238