| Course | NR 603 Advanced Clinical Diagnosis and Practice across the Lifespan Practicum |
|---|---|
| Week | 5 |
| Paper type | Referral rationale |
| Length | About 840 words, 3 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | MSN, Family Nurse Practitioner (FNP) |
| Updated | October 2026 |
Free sample paper for NR 603 Week 5
Referral Rationale: Asking Gastroenterology Whether R.M.'s Iron Deficiency Anemia With Weight Loss Has an Upper or Lower Gut Source, With the Work Done, the Urgency and the Interim Plan
Student Name
College of Nursing, Chamberlain University
NR 603: Advanced Clinical Diagnosis and Practice across the Lifespan Practicum
Instructor Name
Month Day, Year
Referral Rationale: Asking Gastroenterology Whether R.M.'s Iron Deficiency Anemia With Weight Loss Has an Upper or Lower Gut Source, With the Work Done, the Urgency and the Interim Plan
The Question
For R.M., 58, with new iron deficiency anemia (hemoglobin 10.2 g/dL, ferritin 8 ng/mL), 5% unintended weight loss over three months, a year of daily ibuprofen and no prior colorectal screening: is there an upper or lower gastrointestinal source of blood loss, and if a lesion is found, what is it?
Urgency, With a Reason
Urgent: please see within two weeks. The combination of iron deficiency anemia and unintended weight loss in a patient over 50 who has never been screened raises the possibility of colorectal cancer, and guidance supports prompt endoscopic evaluation in this setting (Ko et al., 2020). R.M. is not acutely unwell, so this is not an emergency referral.
What Has Already Been Done
History: fatigue and breathlessness on stairs for three months, weight from 78 to 74 kilograms, slightly looser stools for two months, no visible blood or black stools, no indigestion or swallowing difficulty, ibuprofen 400 mg most days for one year, stopped one week ago. Mostly vegetarian diet. No family history of colorectal cancer known.
Examination: pale, heart rate 94 to 96, abdomen soft with no masses, no enlarged liver or spleen, brown stool on rectal examination.
Results: hemoglobin 10.2 g/dL; mean cell volume 74 fL; platelets 410,000; ferritin 8 ng/mL; transferrin saturation 6%; thyroid, A1c, kidney and liver tests normal; hepatitis C and HIV negative. Celiac antibodies sent; result to follow.
Other causes considered and set aside: overactive thyroid, diabetes, depression and infection, each with the result that made it unlikely.
Why This Exceeds the Primary Care Setting
The question can only be answered by looking inside the stomach and colon, and taking biopsies if needed. Stool tests for blood cannot answer it: a negative test would not exclude a cancer in a patient with symptoms, and a positive one would still need endoscopy. The decision about whether to do upper and lower endoscopy in the same session, and the preparation needed, rests with gastroenterology.
What Is Being Asked Specifically
1. Colonoscopy and upper endoscopy, ideally in one session.
2. Duodenal biopsies if the celiac antibody result is positive, or if the endoscopist judges them useful.
3. If both examinations are normal, advice on whether small bowel evaluation, such as capsule endoscopy, is needed before further primary care workup.
What Happens in the Meantime
R.M. has started ferrous sulfate 325 mg every other day. Ibuprofen and other anti-inflammatory medicines have been stopped; acetaminophen is used for back pain. Hemoglobin will be rechecked in four weeks. R.M. knows to go straight to an emergency department for tarry or bloody stools, a faint, chest pain or breathlessness when resting. The clinic will call R.M. in two weeks to confirm the appointment.
Oral iron given on alternate days is absorbed as well as daily doses with fewer stomach side effects (Stoffel et al., 2017), which matters for a patient who may already have an irritated stomach lining.
What I Will Do With the Answer
If a cause is found and treated, I will follow hemoglobin to recovery and manage iron replacement. If both examinations are normal and weight loss continues, I will arrange imaging of the chest, abdomen and pelvis.
Medicines Relevant to the Procedure
R.M. takes no blood thinners and no diabetes medicines. Oral iron darkens stools, which the endoscopist should know; it can be held for a few days before colonoscopy if preferred.
Patient Preferences
R.M. prefers a morning appointment and can arrange a driver for sedation. R.M. understands that the bowel preparation takes most of the previous day and has asked for written instructions.
Contact
Questions about the history or results before the appointment can come to me by the clinic's secure message system or by phone.
What Would Make This More Urgent
If R.M.'s hemoglobin falls below 9 g/dL at the four-week check, or R.M. develops symptoms of active bleeding, I will call the gastroenterology service directly to arrange an earlier procedure.
Why This Letter Is Written This Way
A referral that says only "iron deficiency anemia, please evaluate" asks the gastroenterologist to begin from nothing. Setting out what has been done, what has been ruled out and what is being asked lets the specialist plan the procedure before seeing R.M. and avoids repeating tests. It also records the urgency and its reason, which helps the scheduling team decide where R.M. sits on the waiting list. The US Preventive Services Task Force (2021) recommends colorectal screening from age 45, so R.M.'s 13 years without screening add to the reason for urgency.
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
Stoffel, N. U., Cercamondi, C. I., Brittenham, G., Zeder, C., Geurts-Moespot, A. J., Swinkels, D. W., Moretti, D., & Zimmermann, M. B. (2017). Iron absorption from oral iron supplements given on consecutive versus alternate days and as single morning doses versus twice-daily split dosing in iron-depleted women: Two open-label, randomised controlled trials. The Lancet Haematology, 4(11), e524-e533. https://doi.org/10.1016/S2352-3026(17)30182-5
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
The Chamberlain NR 603 Week 5 instructions
One sentence decides how the Week 5 referral reads: the question. A weak version refers a patient for evaluation and asks the specialist to start from nothing. A strong one says what is wanted. Around that sentence, show the work already done and the findings that made the local explanation insufficient. Explain why the answer needs a tool primary care does not have. Give an interim plan, since the patient may wait weeks. State urgency with a reason. Most rubrics mark down a referral with no question, a referral that reads as surrender and a missing interim plan. Say what you will do with the answer when it comes back.
Inside the NR 603 Week 5 example
The sample's question asks whether there is an upper or lower gut source of iron loss in a 58-year-old with a ferritin of 8, weight loss, daily ibuprofen and no screening. Urgency is two weeks, with the reason. Work already done lists history, examination, results and the candidates set aside. A section explains why stool testing cannot answer the question. Three specific requests follow: both endoscopies, small bowel biopsies if needed and advice if both are normal. The interim plan covers iron, stopping ibuprofen and warning signs. Sections cover what would raise the urgency, medicines relevant to the procedure, patient preferences, contact and why the letter is written this way.
Where the points sit in the NR 603 Week 5 rubric
The referral with no question in it loses most, and this one states its question first. A referral that reads as surrender costs the next share, while this one argues that the answer needs endoscopy. A missing interim plan leaves the patient with weeks and nothing to take, so iron, a medicine change and warning signs are set out. Urgency asserted without a reason loses a row, and two weeks is justified by the findings. Listing what has been ruled out spares the specialist repeat tests, and saying what will happen with the answer earns the coordination criterion. Listing medicines relevant to the procedure helps the endoscopist plan. Recording the patient's preferences makes the appointment easier to keep.
NR 603 Week 5 help: mistakes that cost points
Weak NR 603 Week 5 referrals ask the specialist to evaluate and treat. Others apologize for not knowing the answer. Many leave the patient with nothing to do while waiting. Urgency is often marked without a reason. Few list the tests already done. Write the question you need answered in one sentence, show what you have done and ruled out, explain why the answer needs the specialist and give the patient a plan for the wait. If your referral differs, share the question and the findings, and we can draft a sample rationale with you. Tell the specialist what would make the case more urgent.
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NR 603 Week 5 questions, answered
Is referring a patient a sign of weak reasoning?
No, and the assignment is built to make that clear. A referral written with a precise question, a completed workup behind it and an interim plan is a demonstration of judgment. What does look weak is a referral that names no question, since it moves a patient without moving the problem any closer to an answer.
How specific should the consultation question be?
Specific enough that the consultant could answer it in a sentence. Asking whether a lesion needs biopsy given two features and a duration is answerable. Asking for evaluation of a rash is not a question at all. The specialty follows from the question, so if the question is vague the referral often goes to the wrong place.
Does the rationale need evidence and citations?
Most sections ask for them and they land best on two points: the criteria that make this patient a candidate for specialty input, and the reason the requested urgency is appropriate. Guideline thresholds are useful there. Citations describing the condition in general terms add length without adding an argument for sending this particular patient.
Where can I find a free NR 603 Week 5 sample paper?
The full referral rationale asking gastroenterology about the source of iron deficiency anemia is on this page.
Why not a stool test instead of referral in the NR 603 Week 5 rationale?
In a patient with symptoms, a negative stool test would not rule out cancer, and a positive one would still need endoscopy.