History and Physical Advice Tips Secrets

How to correctly do a Consult

Below is an explanation of how to do a Consult.

A consult differs slightly from an H&P. A consultant is usually asked to see a patient for a specific reason and for a problem that the primary physician does not have the knowledge to work up, nor the expertise to know which tests to order nor how to treat the issue. The consultant usually focuses on the problem that they are consulted for and tries not to stray into other areas.

The nephrologist may comment that the elevated glucose levels need to be better controlled, but is not going to mess aroud with the patient's insulin regimen. The GI physician is going to address the anemia and bleed, but pass on trying to treat the aortic stenosis.

CC: For a consult, the Chief Complaint should answer the question, "Why are we being consulted?" It should really be "RFC" or Reason For Consult. A few examples could be; Acute Renal Failure, Upper GI Bleed, Respitory Failure, Sepsis, etc. It should not be anything more or anything less.

Sometimes you will see students do a cardiology consult and put down "GI Bleed" as the chief complaint. This is wrong. Yes, the patient may have come in because they have black stool and are losing blood, but the cardiology team was consulted to treat the ensuing acute myocardial infarction. Hence, your CC for the cardiology team should be: "Acute MI". If you want to be more descriptive you could write: "Anemia induced Acute MI".

HPI: Just like an H&P, the HPI should tell 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 are a direct admission, it should describe their whole outpatient story and what was tried, leading up to why they are being admitted, what the primary team tried to do, and why you are now being asked to help. What did the primary attending or team try before consulting you? What has been the hospital course for this patient? When did they receive contrast? Times, dates, interventions, and the reason for consult are important. The HPI in the case of a consult should summarize the patient's story, and have all relevant information leading up to your consult. The HPI is the story of the patient. It is the most useful bit of information. It should answer the questions you have all been taught about; onset, duration, location, radiation, alleviating, aggravating, etc, etc.

Sometimes, a patient will have been in the hospital for a few weeks before you are consulted. This is a difficult consult to do. You will have to go back and read the entire chart, all the other consults, figure out why they were started on all the various drugs and interventions, and finally figure out why you were asked to see the patient. It can be very tedious if they have been here for a while.

Consultants can also do a lot of educating and teaching in their consult. This helps students, residents, as well as other physicians. Sometimes the primary team will order a test that was useless in an attempt to help the consultant out. The primary team figured you need a total and free T3 and T4 as well as a TSH to figure out if the patient has thyroid disease. As a consultant you can politely mention that you simply needed the TSH and free T4. You DO NOT want to ARGUE in the chart with others. Simply state your findnings and your recommendation. The primary physician is still the one in charge of taking care of the patient, and can decide to not follow your recommendations. If you want to argue and discuss things, you can do this in person. Pick up the phone and call the other physician. A chart full of bickering and arguing is a medico legal nightmare. Do not do this! Plus if you are rude, they will find another consultant to use.

You can, however, politely and professionally disagree with someone elses assessment. If you don't think the patient has heart failure or DKA you can state your case. For example, "In light of the patient's acute renal failure, the BNP should not be used to determine heart failure". Or you could write, "I disagree that the patient has DKA, the patient's bicarbonate is 22, glucose is 120, which does not support acidosis. Will check CK for rhabdo". There are ways to disagree without being arguementative.

The HPI is the history of PRESENT illness. Not a past medical history. Too many times you see students and residents (and even attendings) writing out, "This is a 54 year old asthmatic, diabetic, hypertensive, osteopenic patient that presents with a three day history of shortness of breath". That is poor form. What if their shortness of breath is positional, and gets worse when they lie down? What if it is heart failure this time and not their asthma? By stating that "this is a 34 year old asthmatic" you have biased your HPI towards thinking it is the asthma. Stop doing this immediately! This is the single biggest mistake seen on H&Ps. There is a section on the H&P called "Past Medical History" that is where their history should go!

Once again, please do not include the past medical history in the history of PRESENT illness section. Stop biasing your current history taking with old historical information. You can synthesize and use their history later. In this particular part though, just the present symptoms. If you do this correctly, you should easily be able to figure out if the shortness of breath is from heart failure or asthma. Leave the past medical history to the past medical history section!

Of course, some attendings may want you to present a patient in a certain way. Please do it as they request, however know in the back of your mind that you are doing it wrong. When you are the boss, you can do it however you want. Plus you will get paid more if you do your H&Ps properly and address the HPI by itself and the PMH by itself.

PMH, FH, Soc, All, Meds, ROS:

The past medical history, family history, allergies, medications, and review of systems is similar to how you would do it on an H&P, except that you may focus more on your specialty and add details that the primary team may not have asked about. A cardiologist may ask about the patient's exercise history and other risk factors. A nephrologist may ask about other drugs that the patient may have taken or multivitamin pills. An infectitious disease specialist may ask about travel history and sexual history. A pulmonologist may ask about environmental exposures.

Lab work and Imaging: Here you can list the pertinent labs and imaging results. Do not circle any abnormal lab values. Everyone knows they are abnormal. Sometimes you see students and residents circling an elevated glucose or low sodium. This is a medico legal nightmare. Any jury looking at your H&P or Consult will think that all you cared about was the elevated glucose and low sodium, while ignoring the elevated tropinin and extremely low bicarbonate level. Do not do this.

Assessment and Plan: This is similar to how you would do an H&P but with special emphasis on your specialty. The nephrologist will discuss the acute renal failure and how they plan to deal with it, but isn't going to add much more information about the patient's heart conditions or psychiatric illnesses. This should be focused on your specialty. Avoid telling other consultants what to do with their issue, unless it is pertinent. If you are a nephrologist, and feel that the ACE Inhibitor that cardiology started may be worsening the patient's renal function, you may comment that you would like cardiology to hold the ACEI or find an alternative for now, until the kidneys get better. That is tactful and important for the patient. But do not delve into specialties that you do not know much about.

Please DO NOT list things like "History of UTI" and "History of alopecia" and "History of ORIF of tibia" and "History of C-section" and "History of CABG". The Assessment and Plan should be a list of CURRENT, ACUTE problems, and what you are doing to fix them. It should not be a reiteration of their past medical history. The current, acute assessment should include things that can only be treated in the hospital, not their history. Unless of course, they had CABG last week, and are in for a NSTEMI today. That would be pertinent to know, but still can be in the PMH, unless you are calling that CT surgeon or consulting them to help with this case. Do not list a ton of items as "history of X" in an attempt to build your case for a higher level of decision making or higher level of care. History belongs in history section. This section is for their current, acute problems, and how you are treating them.

See the How to do a correct History and Physical section for the remainder of the Assessment and Plan section. It is virtually the same after this part.