| Course | NR 607 Diagnosis & Management in Psychiatric-Mental Health III Practicum |
|---|---|
| Week | 7 |
| Paper type | Consultation write-up |
| Length | About 1,100 words, 4 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | MSN, Psychiatric-Mental Health Nurse Practitioner (PMHNP) |
| Updated | October 2026 |
Free sample paper for NR 607 Week 7
Consultation Write-Up: Asking Hematology Whether K.A.'s Low Neutrophil Count Reflects Duffy-Null Associated Neutrophil Count, and Whether Clozapine Can Start Under the Adjusted Thresholds
Student Name
College of Nursing, Chamberlain University
NR 607: Diagnosis & Management in Psychiatric-Mental Health III Practicum
Instructor Name
Month Day, Year
Consultation Write-Up: Asking Hematology Whether K.A.'s Low Neutrophil Count Reflects Duffy-Null Associated Neutrophil Count, and Whether Clozapine Can Start Under the Adjusted Thresholds
The Question
Is K.A.'s persistently low absolute neutrophil count consistent with Duffy-null associated neutrophil count, previously called benign ethnic neutropenia, and if so, may clozapine be started and monitored using the thresholds for that condition?
Urgency and the Window
Routine but time-sensitive: an answer within four weeks would allow clozapine to start in early January, after K.A.'s move to supportive housing has settled. K.A. is not acutely unwell, and no decision is being made today that depends on the answer.
Only the Bearing Facts
K.A., 27, has treatment-resistant schizophrenia and has agreed to start clozapine.
Absolute neutrophil count on five occasions since 2020: 1,500, 1,300, 1,400, 1,350 and 1,450 per microliter. Total white count 3,200 to 3,800. Hemoglobin and platelets normal.
No history of recurrent or serious infections. No mouth ulcers. No fever with the low counts.
K.A. is of West African ancestry on both sides of the family.
Current medicines: paliperidone palmitate by monthly injection, metformin and a nicotine patch. None is known to lower the neutrophil count.
Duffy blood group phenotype has not been tested.
Where My Thinking Stopped
I know that people of African and Middle Eastern ancestry often have lower neutrophil counts without any increased risk of infection, and that this is linked to the Duffy-null blood group. I know that clozapine labeling and published recommendations allow different starting and monitoring thresholds for these patients, starting at a lower count. Manu et al. (2016), in a systematic review, concluded that people with this condition can be treated with clozapine safely using adjusted thresholds.
What I cannot do is confirm the diagnosis. I do not know whether K.A.'s pattern needs a Duffy phenotype test, whether other causes of a low count need excluding first or whether there is any reason specific to K.A. not to use the adjusted thresholds.
Outside the Question
Hematology was not being asked to decide whether K.A. should have clozapine; that decision is ours and K.A.'s, and the reasons for it are in the attached case analysis. Nor was hematology being asked to run the clozapine blood monitoring.
The Reply
The hematologist saw K.A. on 9 December, arranged a Duffy phenotype test and a peripheral smear and replied on 16 December:
"Duffy phenotype Fy(a-b-), Duffy-null. Smear normal; no other cause found. This is consistent with Duffy-null associated neutrophil count. There is no hematologic contraindication to clozapine. Use the adjusted thresholds for this condition in the prescribing information. If the count falls below 1,000, please contact me before stopping clozapine, unless there is fever or infection."
What Followed
Clozapine was started on 8 January at 12.5 mg at night, with weekly counts using the adjusted thresholds, a baseline electrocardiogram, troponin and C-reactive protein, and weekly troponin and C-reactive protein for the first four weeks to watch for heart inflammation. K.A.'s counts stayed between 1,200 and 1,600 through the first eight weeks. Constipation was managed from the start with a stool softener and a laxative plan, given the known risk.
At twelve weeks, on 350 mg daily, K.A. reported the voices as "quiet most of the day." This is consistent with the established evidence that clozapine is effective where other antipsychotics have not been (Kane et al., 1988).
Why the Question Matters for This Patient
K.A. has treatment-resistant illness under the consensus criteria (Howes et al., 2017), and clozapine is the remaining option with strong evidence. Without an answer to the neutrophil question, K.A. would either be refused clozapine because of a count that is normal for K.A., or started under thresholds that might force an unnecessary stop in the first weeks. Either outcome would deny K.A. the one medicine most likely to help.
What the Consult Included and Left Out
It included the five counts with dates, the infection history, the ancestry, the medicines and the specific decision waiting on the answer. It left out the history of the voices, the suicide attempt and the housing situation, which do not bear on the hematologist's answer. The consult was one page.
How the Answer Was Recorded
The hematologist's reply was added to K.A.'s problem list as "Duffy-null associated neutrophil count, confirmed December 2026; use adjusted clozapine thresholds; contact hematology before stopping for count below 1,000 without infection." This wording was chosen so that any future prescriber, including at an emergency department, would see the answer without needing to find the consult.
Why the Consult Was Written This Way
A consult that said "please evaluate low neutrophils before clozapine" would have asked the hematologist to guess what I needed. Naming Duffy-null associated neutrophil count, giving the five counts, the infection history and the ancestry, and saying exactly what decision depended on the answer, allowed the hematologist to order the right test at the first visit.
How Long the Consult Took
From request to reply: 26 days, including a two-week wait for the appointment and a week for the Duffy test. A pre-consult Duffy test through primary care would have shortened this to about two weeks. During the wait, K.A. continued paliperidone injections and the team did not start clozapine, which kept the wait safe if slower, and K.A. was told the reason for the delay.
What the Reply Changed Beyond This Decision
The answer will matter again whenever K.A. has a blood count for any reason, including infections and surgery. A low count that would alarm an emergency clinician is normal for K.A. Recording the condition clearly prevents unnecessary stops of clozapine and unnecessary investigations in future.
How K.A. Was Kept Informed
K.A. was told before the referral why hematology was involved, that a low count can be normal for some people and that a test could show whether that was true for K.A. K.A. went to the appointment with the sister. After the reply, K.A. was told the result at the next visit and given a printed card stating the condition, to show any clinician who might see a low count and worry.
What I Would Do Differently
I would have asked for the Duffy phenotype test myself, through primary care, before the consult, so that the hematologist would have had the result at the first visit. That would have saved a week.
References
Howes, O. D., McCutcheon, R., Agid, O., de Bartolomeis, A., van Beveren, N. J. M., Birnbaum, M. L., Bloomfield, M. A. P., Bressan, R. A., Buchanan, R. W., Carpenter, W. T., Castle, D. J., Citrome, L., Daskalakis, Z. J., Davidson, M., Drake, R. J., Dursun, S., Ebdrup, B. H., Elkis, H., Falkai, P., ... Correll, C. U. (2017). Treatment-resistant schizophrenia: Treatment Response and Resistance in Psychosis (TRRIP) working group consensus guidelines on diagnosis and terminology. American Journal of Psychiatry, 174(3), 216-229. https://doi.org/10.1176/appi.ajp.2016.16050503
Kane, J., Honigfeld, G., Singer, J., & Meltzer, H. (1988). Clozapine for the treatment-resistant schizophrenic: A double-blind comparison with chlorpromazine. Archives of General Psychiatry, 45(9), 789-796. https://doi.org/10.1001/archpsyc.1988.01800330013001
Manu, P., Sarvaiya, N., Rogozea, L. M., Kane, J. M., & Correll, C. U. (2016). Benign ethnic neutropenia and clozapine use: A systematic review of the evidence and treatment recommendations. The Journal of Clinical Psychiatry, 77(7), e909-e916. https://doi.org/10.4088/JCP.15r10085
What the NR 607 Week 7 assignment asks for
The Week 7 consult puts a question in its opening sentence, not a summary followed by a hope. Questions such as whether an agent should continue through pregnancy, or whether a dose can go higher given a result, can be answered by someone who has never met the person, provided you supply what answering needs. State urgency and the time window. Give only the bearing facts. Say where your own thinking stopped. Record the reply and what followed. Most rubrics mark down a consult asking a specialist to evaluate and advise, a question asked without the information needed to answer it, no urgency and no interim plan.
How the NR 607 Week 7 example is put together
The sample asks whether a low neutrophil count is consistent with Duffy-null associated neutrophil count and whether clozapine may start under the adjusted thresholds. Urgency is routine with a four-week window. Bearing facts include five counts since 2020, normal hemoglobin and platelets, no infections, West African ancestry and current medicines. The writer explains what is known, citing a systematic review, and what cannot be decided without hematology. The reply confirms Duffy-null and gives a threshold for contact. Sections cover what followed with clozapine, why the question matters, what the consult included and left out, how the answer was recorded and what the writer would do differently.
Reading the NR 607 Week 7 grading rubric
The costliest consult asks nothing, handing the specialist the work of guessing the question; this one asks a single answerable question. A question without the information to answer it costs the next share, while the five counts, infection history and ancestry are all given. Missing urgency and window lose a row, and both are stated. Saying where the writer's thinking stopped earns credit, as does stating what is not being asked. Recording the answer on the problem list, in words a future prescriber can act on, shows the consult was used. Saying what the writer would do differently, testing the Duffy phenotype first, shows reflection on the process. Explaining what the answer changes beyond this decision shows foresight.
Common NR 607 Week 7 mistakes, and how to avoid them
Weak NR 607 Week 7 consults ask the specialist to evaluate and recommend. Others ask a precise question but leave out the results needed to answer it. Many give no urgency or timeframe. Few say what the writer already knows and where uncertainty begins. Replies are often not recorded in a way the next clinician will find. Ask one question that can be answered on paper, supply only the facts that bear on it, state urgency and explain where your own reasoning stops. Then record the answer where it will be seen. For your own consult, start from the single question you need answered, and a sample built on it can be prepared.
Get a NR 607 Week 7 example written to your instructions
Send the Week 7 prompt from your classroom and the question your case turns on, and a custom example is written to it and returned inside 24 to 48 hours. The first one is free. If your section names the service being consulted, include that and the example is addressed there.
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NR 607 Week 7 questions, answered
Can I ask more than one question?
You can, numbered, but each needs its own supporting detail and its own answer. Three questions buried in a paragraph usually come back with one answered and two ignored. Where they are genuinely separate, most write-ups read better with the primary question first and the rest marked secondary, so a busy colleague can stop after the part that mattered.
What if I disagree with the advice?
Record the advice, record what was done instead, and give the reason at the time. Departing from a consultant's view is legitimate and gets documented rather than quietly dropped. A record showing advice sought, considered and not followed for stated reasons is defensible. One showing advice received and no action at all is the version that causes trouble later.
Does the consultation have to be to a psychiatrist?
Not usually. Prompts in this area commonly involve pharmacy, primary care, neurology, obstetrics or a substance use service, and those cross-service questions are often the better material. What gets marked is whether a reader outside your own specialty can act on what you sent, which is harder when they do not share your vocabulary.
Where can I find a free NR 607 Week 7 sample paper?
The full consultation write-up asking hematology about a low neutrophil count before clozapine is on this page.
What did the hematology reply say in the NR 607 Week 7 consult?
The patient is Duffy-null, there is no hematologic reason to avoid clozapine and adjusted thresholds apply, with a call before stopping if the count falls below 1,000.