Posted: July 25th, 2016
Details: Develop a consultation report for Patient 3 and Patient 4 from “Case Study Patients.” Chose a relevant specialty and develop this consultation report as if you were a specialist called in for a consult. For each patient, use the “Consultation Note.” Within the template, use your professional experience to complete additional information that you believe to be relevant but is not explicitly presented within the case study. APA format is not required, but solid academic writing is expected. This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. You are not required to submit this assignment to Turnitin. RUBRIC FORMAT : 100.0 %Module 7 Rubric: Consultation of Special Services Case Study 15.0 %Essential Consultation Note Components Includes concise but comprehensive summary of subjective and objective assessment, including studies and interventions. Current hospital course is concise and comprehensive. Final findings are explained. Evidencebased plan with specific details clearly is presented, including recommended interventions. 20.0 %Differential Diagnosis Articulates the differential diagnosis and the decision making with rationale for a final diagnosis. Demonstrates the ability to do a differential diagnosis by generating a list of diagnoses that fit the symptoms and systematically eliminating some. Presents a clear argument for support of the final diagnosis. 35.0 %EvidenceBased Treatment Plan The evidencebased treatment plan included the following: 1) Appropriate lab (indepth rationale) 2) Imaging (indepth rationale) 3) Pharmacology and medical treatments (indepth rationale) 4) Ethical/legal issues 5) Geriatric concerns related to the cases in general 6) Supportive therapies, disease prevention, health promotion. The plan is written with a logical progression of ideas and supporting information exhibiting a unity, coherence, and cohesiveness. Includes information from reliable sources. The plan is written clearly and concisely. Ideas universally progress and relate to each other. 15.0 %Mechanics of Writing (includes spelling, punctuation, grammar, language use) The writer is clearly in command of standard, written academic English. 15.0 %Research Citations (intext citations for paraphrasing and direct quotes, and references page listing and formatting, as appropriate to assignment and style) Intext citations and a references page are complete. The documentation of cited sources is free of errors. SCENARIO: PATIENT 3 PJ was writing a paper on her computer this morning and began to feel lightheaded. She stopped writing and went to the kitchen and had some fruit juice. Her lightheaded sensation did not resolve. In fact, it worsened. She began to feel her heart âracing and flopping around.â She called her husband who came home from work and then brought her to the ED. She reluctantly admits to some mild chest discomfort. PJ states that she is 72 years old and has never felt this way before. The only medication she takes is Levoxyl 0.025 mg daily, and she has taken this for many years. She has never smoked, has never had surgery, and has no other medical problems. PATIENT 4 BJ is a 60yearold male with acute onset severe dyspnea. His BP has been in the 160/98 range. There is intermittent SVT and he was admitted to the ICU. There is a history of CAD not requiring intervention other than Lipitor and a history of TIA. He denies chest pain. Consultation Note REFERRING PHYSICIAN: REASON FOR CONSULTATION: HISTORY OF PRESENT ILLNESS: MEDICATIONS: ALLERGIES: PAST MEDICALSURGICAL HISTORY: SOCIAL HISTORY: FAMILY HISTORY: REVIEW OF SYSTEMS: GENERAL: RESPIRATORY: CARDIAC: GASTROINTESTINAL: GENITOURINARY: MUSCULOSKELETAL: NEUROLOGIC: INTEGUMENT: PHYSICAL EXAMINATION: VITAL SIGNS: SKIN: HEENT: NECK: LUNGS: CARDIAC: ABDOMEN: RECTAL: E
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