Name of the Procedure:

Follow-up Inpatient Consultation (for Established Patient)

Summary

A follow-up inpatient consultation involves a detailed assessment of a patient already admitted to the hospital. This procedure incorporates taking a thorough history, performing a detailed physical examination, and making complex medical decisions to address ongoing or new health issues.

Purpose

The procedure addresses ongoing or new medical conditions in hospitalized patients. The goal is to monitor progress, adjust treatment plans, and manage any complications.

Indications

• Worsening of existing medical conditions
• New symptoms or medical issues
• Assessment of treatment efficacy
• Need for specialized medical opinion or interdepartmental collaboration

Preparation

• No specific preparation required for the patient
• The consulting physician will review the patient's medical records, current treatment plan, and any recent diagnostic test results beforehand.

Procedure Description

1. Interval History Collection: The physician gathers detailed information about the patient's current condition, changes since the last visit, and any new symptoms.
2. Physical Examination: A thorough physical examination is conducted, focusing on relevant systems based on the patient's condition.
3. Medical Decision Making: The physician evaluates the information, formulates a diagnosis, and updates the treatment plan. Discussions with other specialists may occur if necessary.
4. Counseling and Coordination: The physician may also engage in detailed counseling with the patient and coordinate with other healthcare providers.

Duration

Typically, this consultation can take between 30 minutes to 1 hour, depending on the complexity of the case.

Setting

Performed in a hospital where the patient is already admitted.

Personnel

• Attending physician or specialist
• Nurses may assist with gathering medical information and performing parts of the physical examination.

Risks and Complications

• Minimal risk, as it is a non-invasive evaluation
• Possible misinterpretation of symptoms due to the patient’s complex medical status, which might require additional follow-up

Benefits

• Improved management of ongoing medical conditions
• Timely identification and intervention of new health issues
• Enhanced coordination of care among different specialties

Recovery

• No recovery time required from the consultation itself
• Continuous monitoring and treatment adjustment as needed based on consultation findings

Alternatives

• Outpatient consultation after discharge (not feasible for acute issues)
• Telemedicine consultation if patient status allows

Patient Experience

• The patient can expect detailed questioning about their health status and a physical examination.
• Minor discomfort may arise during the physical exam, but there is no significant pain involved.
• The consultation aims to provide reassurance through proactive management of health conditions.