How to correctly do a Consult
A consult is not an admission H&P with a different heading on it. Here is what changes, and why those changes matter.
What a consultant is actually for
A consultant is usually asked to see a patient for a specific reason, for a problem the primary physician does not have the expertise to work up, does not know which tests to order for, or does not know how to treat. The consultant focuses on the problem they were consulted for and tries not to stray into other areas.
The nephrologist may comment that the glucose needs better control, but is not going to start rewriting the insulin regimen. The GI physician addresses the anemia and the bleed, and passes on the aortic stenosis.
CC Really the reason for consult
On a consult, the chief complaint should answer one question: why are we being consulted? It is really an RFC, a reason for consult. Acute renal failure. Upper GI bleed. Respiratory failure. Sepsis. It should be nothing more and nothing less than that.
Sometimes you will see a student doing a cardiology consult put down "GI bleed" as the chief complaint. That is wrong. Yes, the patient came in with black stool and blood loss. But the cardiology team was consulted to treat the myocardial infarction that followed. So the chief complaint for the cardiology team is "acute MI." If you want to be more descriptive, "anemia induced acute MI."
HPI History of present illness
Just like an H&P, the HPI tells the story of the patient from the time they hit the door, if they came in through the ER, to the moment you are seeing them for the consult. If they were a direct admission, describe the outpatient story, what was tried, and why they were admitted.
Then add the part that is unique to a consult: what did the primary attending or team try before consulting you? What has the hospital course been? When did they receive contrast? Times, dates, interventions and the reason for consult all matter. The consult HPI should summarize the patient's story and carry every relevant piece of information leading up to your involvement.
It should still answer everything you were taught to ask: onset, duration, location, radiation, quality, severity, timing, alleviating and aggravating factors.
Sometimes a patient has been in the hospital for a few weeks before you are consulted. Those are hard. You have to go back through the entire chart, read the other consults, work out why they were started on each of the various drugs and interventions, and only then work out why you were asked to see them. It is tedious, and it is the job.
The HPI is the history of present illness. It is not a past medical history.
Too many times you see students and residents, and even attendings, writing "this is a 54 year old asthmatic, diabetic, hypertensive, osteopenic patient who presents with a three day history of shortness of breath." That is poor form. What if the shortness of breath is positional and worse lying down? What if this time it is heart failure, not the asthma? By opening with "this is a 54 year old asthmatic" you have already biased the history toward the asthma.
Stop doing this immediately. There is a section called past medical history. That is where it goes.
Once again: do not put the past medical history into the history of present illness. Stop biasing your history taking with old historical information. You can synthesize and use their history later. Here, just the present symptoms.
Some attendings want a patient presented a particular way. Do it as they ask. Just know it is wrong, and that when you are in charge you can do it properly. You will also be paid more when the HPI and the past medical history are addressed separately.
Teaching in the chart, and how to disagree
Consultants can do a great deal of teaching in the consult itself. It helps students, residents and other physicians. Sometimes the primary team will order a test that was not needed, in an attempt to help you out. They ordered a total and free T3 and T4 as well as a TSH to work out whether the patient has thyroid disease. As a consultant you can note politely that a TSH and a free T4 were all that were needed.
State your findings and your recommendation. The primary physician is still the one caring for the patient and may decide not to follow your advice. If you want to argue about it, do it in person. Pick up the phone. A chart full of bickering is a medicolegal nightmare, and if you are rude in writing, they will simply find another consultant next time.
You can, however, disagree politely and professionally. If you do not think the patient has heart failure or DKA, make your case:
Disagreeing well
"In light of the patient's acute renal failure, the BNP should not be used to determine heart failure."
"I disagree that the patient has DKA. The bicarbonate is 22 and the glucose is 120, which does not support an acidosis. Will check CK for rhabdomyolysis."
There are ways to disagree without being argumentative.
PMH, FH, Soc, All, Meds and ROS
The past medical history, family history, social history, allergies, medications and review of systems are handled much as they are on an H&P, except that you focus more on your specialty and add the detail the primary team would not have thought to ask about.
- A cardiologist asks about exercise tolerance and the full risk factor profile.
- A nephrologist asks about every other drug, supplement and over the counter product they have taken.
- An infectious disease specialist asks about travel and sexual history.
- A pulmonologist asks about occupational and environmental exposures.
On medications specifically: list what they are currently on in the hospital, with the dates that doses changed or new drugs were added.
Lab work and imaging
List the pertinent labs and imaging results.
Everyone knows they are abnormal. Sometimes you see students and residents circling an elevated glucose or a low sodium. That is a medicolegal problem. Any jury reading your H&P or consult will conclude that all you cared about was the glucose and the sodium, while you ignored the elevated troponin and the extremely low bicarbonate. Do not do it.
Assessment and plan
This is similar to an H&P, with special emphasis on your specialty. The nephrologist discusses the acute renal failure and how they plan to deal with it, and does not add much about the patient's cardiac or psychiatric conditions. Keep it focused.
Avoid telling other consultants what to do with their problem, unless it is genuinely pertinent to yours. If you are the nephrologist and you believe the ACE inhibitor cardiology started is worsening renal function, it is entirely appropriate to write that you would like cardiology to hold it or find an alternative until the kidneys recover. That is tactful and it is important for the patient. But do not wander into specialties you do not know well.
Please do not list "history of UTI," "history of alopecia," "history of ORIF of tibia," "history of C-section," "history of CABG." The assessment and plan is a list of current, acute problems and what you are doing to fix them. It is not a second copy of the past medical history.
If they had a CABG last week and are in today with an NSTEMI, that is pertinent, and it still belongs in the past medical history unless you are consulting the surgeon about it. Padding the list with "history of X" items to build a case for a higher level of care does not work. History belongs in the history.
See the guide to the admission history and physical for the remainder of the assessment and plan section. After this point the two are virtually the same.