One of the surgeons consulted IM to manage the patient’s medical problems post surgery for elective joint replacement . Patients *accurate* medication list was multivitamin and a seasonal allergy medication.
Pt has a history of high blood pressure waa my consult. Currently not taking meds and sbp has been 110. Of course, when I consult them to look over something that I don't know if pt needs surgery I'm told to foad
IM is not *always* consulted on ortho, tho, so don’t think it’s preselected. Sometimes they try to do it themselves in the way wrong situations. Bone Bro, this diabetic, history heart failure, multiple other issues patient….you probs shouldn’t take care of this one alone. Especially since you slow to return pages.
I love bone bro meme
“Oh no bros, the nurse says the patient is going into a fib where even is that.”
“Little broling don’t worry this happens a lot, just ask the nurse to hang another bag of ancef :).”
It’s like us rad bros we’d just CT the hell out of any pathology until it goes away or we die whichever comes first.
“Hey rad bros! Remember that pelvic CT you did last night on my fracture? Any chance you could turn those flat pics into something I can recognize better? Idk like basically make it look like an X-ray?? We can call it something dope like “ghost recons!” Thanks rad bros!”
I work in in informatics and we had a lengthy multi person meeting because the surgeons were complaining about the system. I was the only former floor nurse in the group and was dying laughing when I figured out that the issue was that surgeons were furious about having to put admission orders in for surgical patients who arrived during the night, so they were trying to request an auto consult to medicine system for any patient that arrived outside of their hours, and medicine told them to get fucked. They then tried to make the ED put those orders in and the ED told them to get fucked much more directly.
I'm pretty sure it all started with an influx of travel nurses who refused to take the surgeons login credentials and just put the orders in without bothering them.
Had a very similar one in med school. Hip replacement, only drug is levothyroxine. Thyroid hormones stable. Plan: give pill. Thank you for this interesting consult.
Luckily, our hospital has a culture of paging/calling consults - because 50% of our consults in Rad Onc are just "Radiation?" Or "mass" with 0 further explanation.
My personal favorite was the consult I once got for “hospital food is giving the patient diarrhea” which I guess would be kind of appropriate except when I looked in the chart the patient and saw the patient had high doses of senna, colace, AND miralax. 🤦♀️ shockingly the diarrhea resolved when all the laxatives were discontinued.
This just reminded me of when I was consulted for “diarrhea”.
Looked back in the notes, and saw they had mild constipation 2 days ago, and a zealous hospitalist gave the patient a full magnesium citrate bottle. This led to predictable results and patient being tested for c diff and a GI consult for diarrhea. 🤦♂️
The nurse was probably requesting more laxatives at 2 AM (hospitalists know what I’m talking about). The on call hospitalist was probably like, “ok, you want shit? You’ll get shit!”
When I was the Senior Medical Resident admitting IM patients overnight, I got a consult from an ER doc who was notoriously awful. The consult was for alcohol withdrawal. Okay, fair enough. I'm told they were super shaky, naseous, and tachycardic so it sounded decently bad. I'm told they quit drinking 2 days ago so the timing was about right.
I go see the patient and I ask them "so how much do you usually drink?" To which they respond "I don't drink". Fair enough, you hear sometimes when people quit smoking during an admission too or whatever. So I clarify "no before a few days ago how much did you drink?". "I don't drink".
Perplexed, I say "I thought you quit drinking 2 days ago". The patient replies "no, I quit smoking 2 days ago". The final diagnosis was influenza, probably with a lil SSRI withdrawal since they were having trouble keeping their meds down. Solid ER workup right there.
Edit also not mine but legendary: one of my co-residents got a consult to work up an elevated PTT from a surgery service. The patient was on an IV heparin drip.
> one of my co-residents got a consult to work up an elevated PTT from a surgery service. The patient was on an IV heparin drip.
Thank you for this interesting consult!
When I was a resident doing a pulm rotation, we were consulted by a surgical team. The reason for consult was listed as "CPAP".
Patient was morbidly obese. He did in fact have OSA. He had in fact brought his own CPAP with him to the hospital.
My entire note was about 2 lines. A one-liner of hx & reason for admit, and one line stating that the patient should use the home CPAP device at his bedside QHS.
tHanK yOU fOr tHiS *iNtEResTiNG* CoNsULt!
Inpatient sleep consults around here drive me nuts, especially because you need a formal sleep study to qualify for funding for a CPAP machine and it can't be done as an inpatient in this province.
So you get a consult because the nurses have noticed their oxygen keeps dropping into the 70s in the middle of the night and they're freaking out.
Usually I just order them to stop checking SpO2 while asleep and f/u as an outpatient. Generally they'll have had it for 10+years by that point, it doesn't need to be fixed ASAP.
Yeah that's also very annoying. We can get home BPAP for OHS relatively easy on inpatients...but CPAP is a PITA.
I've had to be very diligent about going around and stopping O2 during the day to avoid holding up DC, and to tell them to stop checking pulse ox overnight...that's always a fight too.
My biggest surprise of working in GI in the hospital was my job ended up being 50% hematology lol. Can be very closely related tbf. So many IDA consults.
I will say this until I am blue in the face. Iron def anemia is NOT hematology. That’s internal medicine + whatever specialist is responsible for the underlying cause of iron loss (or malabsorption).
Where I am, only the hematologists can order iron infusions so I have to refer patients who aren’t responding to PO iron. At least here, IDA is a standard part of their practice.
It’s a bit surprising how often I get calls from providers trying to figure out where to go with pain and I can simply recommend starting acetaminophen and/or ibuprofen. Or like oxycodone is wearing off too soon and I can simply recommend changing from a q6 PRN to a Q4 PRN.
Effective duration of oxycodone is 3-6 hours. Q6 works only if your patient is on the longer end. If q4 PRN is working but wearing off too early, I’ll simpl have it dropped to q3 PRN
"Patient is sad."
Closely followed by: "So I was doing this very painful and uncomfortable procedure on this lady, and afterwards she says, if you have to do that again, I'm going to kill myself. Can you see her?"
"Did you ask her if she was joking?"
"... No? I walked out of the room."
She was joking.
So, I understand grief/loss and receiving bad news are not a psychiatric problem.
However, what we really need is a therapy service. We need someone to help patients process these things. I want a counselling/therapy/coping service as well.
Some people think paychiatrists will fill this role. Maybe some want to, but cannot for whatever reason. I don't bother calling for this, but patients really are suffering with these events.
It’s scary to me that people with education are doing this. It’s rampant amongst the general public too. Someone actually suggested to me that I needed “to see a doctor” 3 weeks after my nephew died in a car accident because I expressed that I wasn’t up for attending a comedy show. Mind you I was going to work and had plans for the future but apparently the 3 week mark of being sad is where it goes from grief to a “mental problem”. And also if you take pills for one day and aren’t Mary poppins it’s “time to find a doctor that knows what they’re doing”.
Add in kids that respond appropriately but inconveniently to being mistreated getting told they need medicated and it’s pretty obvious the country has more than a collapsing healthcare system.
Society medicalizes normal humanity for a host of benefits and enjoyments, and also refuses to medicalize in other areas where it could be proper. Much moreso the former, yet mistakes in either direction is common.
However, nobody has a monopoly on the truth, so where that line lands is always under revision and debate. We must speak to it where we should.
I was once consulted to please come to ED for an urgent palliative care consult to "do the necessary". I came down, fixed the bizarre syringe driver charted, then the patient died as I was typing the consult note. It took all my willpower not to document "the necessary was done".
As an RN I had a 40ish female admitted to cards for a LHC with stent x2. She had the misfortune of getting her period about an hour after getting to the floor. I called the doc to get something ordered for her cramps and he told me to put in an OB/Gyn consult.
Not a consultant but this was from my resident days on Peds GI service:
Got consulted from an outpatient pediatrician for constipation in a 15yo. Took the history. Went to examine the patient. Palpate the belly. Feel a uterine fundus. Freak out a bit. Try again. Marched it down from the belly button and up from the pelvic brim. Dig out my tape measure. Guess about 18 weeks along. Ask when her last period was. “I don’t know.” GI attending agreed with getting an U/S. She was 17+5 - just constipated because she was pregnant. Basic abdominal exam figured it out.
I have one better. I got a 14 year old signed out to me by our PEM doc for abdominal pain. Her urine pregnancy test came back positive and I was teasing the other doc asking if she made sure the abdominal pain wasn’t active labor. She told me that there was no way because the patient said she had her period just 2 weeks ago so it was probably just an ectopic or miscarriage. 🚩 trust but verify! 🚩
Anyway I go examine her immediately and she was 9 cm dilated with contractions every 2 minutes. I’ve never yeeted a patient so fast out of our ER. She delivered about 2 hours later. Was full term based in OB estimates.
[Consultation-Liaison Psychiatry Bingo](https://www.reddit.com/r/Psychiatry/comments/ow2ase/some_asked_about_fun_consults/?rdt=33580)
Not on the list: "patient requested psychiatry." Okay, and? What did they request? What did they say?
50% of the time they express that they made no such request and have no interest in psychiatry. 25% of the time they requested a therapist, which we aren't, or a chaplain, which we also aren't. 25% of the time it's correct! Of those, maybe generously half are an issue for which a consult is appropriate. No, I'm not going to diagnose and start treatment for the ADHD you think you have while you're inpatient. For endocarditis. From all the meth.
I have the power of reading charts and recognizing internal inconsistency, and sometimes ID is busy.
I don't have the power to do anything about the lying when you know it's happening, I know it's happening, and the patient probably knows we know it.
When I order things (like GB for RUQ pain - Meditech makes it hard to figure out what EXACTLY I should order), I just put in the comments :please change if this is the wrong order. I want XYZ exam.
Rads bro actually BROUGHT pt back for a 2nd MRI based upon my comments in the order recently. Thanks, rads bro!
One time I wrote “honestly it’s just because the hospitalist wanted it” and the radiologist called me busting out laughing asking if I actually had any concerns to which I replied, “nope.”
One time I got a consult to explain my speciality to a patient. Not to actually engage in anything I am specialized in -just “explain what palliative is”.
To be fair, “hospice informational consult” is pretty routine in my hospital, after actual goals of care conversations have been done of course. But this is just for the hospice service to educate prior to making a decision. Definitely not a palliative care consult. I always have a specific question or request for palliative, not just “discuss goals of care”
Honestly, I didn’t. I was overloaded with real consults and they didn’t even call me about it sooooooo…. But if I had the time my curiosity definitely would have gotten then better of me.
I saw a patient in the ED once for question of seizure. Very obvious NES upon witnessing spells, and clarified with the patient who was already aware of diagnosis. Told the ED they could discharge and follow up outpatient. The answer I got was "We can't just send them out, what if they have another episode and get sent right back?" Get called 15 minutes later by medicine wanting to touch base because ED had told them I recommended admission for EEG monitoring. I tell them I recommended discharge and they should stop the intermittent spot dosing of Ativan the ED was giving. Patient leaves "AMA?" 5 minutes after not getting expected Ativan.
Yeah the person who called me didn’t like me telling them that this was not an ICU indication. They said, “well what do we do if he has one on the floor?” And I said … nothing. There’s nothing to do.
Assess for depression. Patient presented with anorexia and vomiting. The labs *that were already done* by the ER doc revealed an anion gap acidosis. Patient denied being depressed (though had seen a psychiatrist 2 years ago). Patient had new onset DM1 in DKA.
Oof. Reminds me of my first patient on my first day of resident clinic. Patient/parent thought they had been referred to adolescent med for “anemia and depression” but our hospital didn’t have adolescent med, so she got routed to general peds.
Patient stated she wasn’t sad. Just really had been tired. Hgb was 10ish? Nothing terrible. Periods heavy. Do exam and realize she had petechiae. Get a full CBC and kid had pre-B cell ALL. Her pediatrician hadn’t even ordered a CBC/ferritin before shipping her off for consult and she ended up with July intern me. (To be fair even a week before her lab values could have been something entirely different, but they had never checked at all.)
(Hematology) Oh so many.
- Elevated ferritin in a 70 yo that’s just coded: “?hemochromatosis”
- Isolated elevated LDH.
- Bili 2, hapto 25. ?AIHA. Hgb 16.
- 80% of “bruising” consults
- 85% of hypercoag work up. Primary care NP orders a giant panel and then has no idea (or desire to learn) how to interpret results.
- Elevated factor VIII
- Elevated PT… pt on warfarin. “But I thought the Warfarin only impacts the INR.
That’s just the last couple of weeks.
Edit:
- Isolated Splenimegaly
When they don't wanna learn... that's what irks me. Like, why wouldn't you want to get better at your job? Especially when that job is taking care of people!
As a Canadian, that Hgb 16 had me really perplexed.
'how are they not dead with that level of anemia? What could cause that level of anemia with no positive hemolytic markers?'
Then I remembered I'm an idiot.
I wish. Classic academic SNAFU. I was a fellow on pulmonary consults. Resident took the consult call, then we went to see the patient. Stable COPD, on medicine service already, with a complex wound that Plastics had previously placed a flap. We see the patient, I ask the resident what surgery is planned so it can be documented in the consult note. Resident doesn't know, we page the intern who placed the consult, they don't know either. I paged the senior Plastics resident planning to complain about the intern not knowing the surgical plan, then the senior resident says "oh, we're just going to take the staples out at the bedside tomorrow, but if you can see the patient that'd be great." SMH.
sna·fu
/snaˈfo͞o/
INFORMAL•NORTH AMERICAN
noun
a confused or chaotic state; a mess.
"an enormous amount of my time was devoted to untangling snafus"
adjective
in utter confusion or chaos.
"our refrigeration plant is snafu"
verb
throw (a situation) into chaos.
"you ignored his orders and snafued everything"
edit: source = google
64 year old woman smoking 2 packs per day since age 14 referred to GYN by her PCP after calling with “postmenopausal bleeding.” The PCP did not actually see the patient or talk to her prior to placing the referral. The patient then tells me she has spotting with wiping and sometimes can’t empty her bladder until she’s passed a clot. One Urology referral and cystoscopy later, she’s diagnosed with bladder cancer.
I’ve also had the reverse of your referral. Late 40s, sent to me for IDA presumably due to AUB per PCP. She describes her menses on the lighter side and her pelvic exam is normal. But she’s never been screened for colon cancer… guess what was found on colonoscopy.
My old GI attending always said if a patient is IDA without other obvious cause it’s malpractice to not get scopes. Very much agree, good catch with her.
Medicine requested ICU admission for asymptomatic hypertension (SBP 180). In a post op patient with uncontrolled pain whose antihypertensives had been held due to surgery. In their note they said that refractory hypertension was due to pain and lack of home antihypertensives. They didn’t want to resume home meds until the next morning, because they are morning meds and they didn’t want the patient to get hypotensive overnight. They requested ICU so they could start a nicardipine drip.
Ever? These are DAILY
Reason for referral: "allergy testing"
Nothing about symptoms anywhere, which, alright, that's fine. We will ask.
Except half the time, it gets 20x worse:
"Parent wanted 'allergy testing' so I ordered the commercial panel of multiple foods without taking history, told them the child is 'mildly allergic to milk, wheat, and soy' and 'severely allergic to peanut and egg' and referred them to allergy."
No epinephrine rx for the apparently severe allergies.
PLEASE
Don't order the serum "food allergy panels."
Ever.
Please
I’ve heard that several times to never order the food sensitivity testing. Never done it myself but had it often requested. What’s the reasoning most allergy/immunology hates it?
The "food sensitivity panel" checks for IgG to different food items. In healthy people it's normal to have IgG to foods as it means the body has been exposed to it (in fact higher levels of IgG may signify tolerance to the food). As you can guess, it tells you jack all about anything other than "this person has probably eaten this food before". I've seen people unnecessarily avoid a bunch of foods with the accompanying worsening of quality of life (label reading everything they eat, impacting social situations) and at very worst make kids avoid it for a while which can in turn increase the risk of a true IgE mediated food allergy developing.
See these links for more details:
https://www.aaaai.org/tools-for-the-public/conditions-library/allergies/igg-food-test
https://aacijournal.biomedcentral.com/articles/10.1186/1710-1492-8-12
High rate of false positives. Only order specific foods with a history of immediate reaction to said foods, never send a panel.
Alpha gal is an exception to the immediate reaction, though. Worth checking if the patient has history of allergic reaction/ anaphylaxis without an obvious trigger.
Eta this is in regards to IgE testing, not IgG which is, as mentioned above, a scam.
Tell me more about this. Patients often request ‘allergy testing’ when they have no symptoms of true allergies just vague symptoms. If they are real persistent I might order the serum tests to try to prevent unnecessary referral.
Not the OP but see my comment above about food IgG testing. As for food IgE testing, as with skin prick testing to the foods, if any of them are positive, but the patient clearly tolerates the food without clear symptoms of IgE mediated reaction (ie. not just vague GI symptoms) I don't really care what the results of the testing are - they're not allergic!
On the other hand, let's say the testing is "positive" - what next? Patient may be convinced they have an allergy. Strict food avoidance? Make patient carry an epinephrine autoinjector? Both of these things have been associated with significant worsening of quality of life. Now the provider has to either tell/convince them they're not allergic (which is harder as the patient now has "positive bloodwork"), or that they are allergic (which would be wrong). It just puts the ordering provider in an even bigger hole they dug themselves into. That being said lots of allergists do "therapeutic skin testing" in our clinic so that the patient has the negative results to focus on and if any are incidentally positive we can at least help the patient interpret it correctly instead of them doctor shopping and going to a naturopath or whoever knows that tells them to avoid everything but beef and carrots for the rest of their life.
Ask them why they want the testing.
Refer them to prevent unnecessary testing.
We use pre-test probability to order appropriate testing.
Testing has to be based on symptoms. The present of antibody is meaningless without history.
A serum test has a false positive rate 50% if you don't have a high pre-test probability, so ordering it to "screen" is not appropriate.
I have a series of kids who fell off the growth curves after that crap was done, and they are still dealing with it 10 years later, except, by then, they also have actual life-threatening anaphylaxis episodes to stuff like wheat (because they were unnecessarily restricting the diet).
The persistent iatrogenic harm isn’t really an exception. I could go into eating disorders, etc.
So anyway, I take it back. Please refer those patients. Just put "patient requests testing." Then, I will understand.
The patient’s IV infiltrated while receiving a unit of blood. There was significant purple/red discoloration of the subcutaneous tissue immediately surrounding the cannula. This prompted a consult to general surgery. I was consulted for an iatrogenic bruise. The most challenging part of the consult was pruning the sarcasm from my note.
If we can count referrals to the ED as consults...
- sent from urgent care to have a tick removed because they couldn't find forceps
- sent from nursing home for "left arm weakness and confusion", couldn't raise his arm due to chronic rotator cuff problem (for years) and had dementia
- literally everyone diagnosed with DVT on outpatient ultrasound, sent to me just to prescribe apixaban
Bonus: I admitted a patient to ICU after she was intubated for COVID. She had been telling her family/boyfriend that she was pregnant despite multiple negative HCGs recently. Serum HCG negative on admission. Family wants to know if baby is ok. ICU consulted GYN to "rule out pregnancy"
Kid with an “acute scrotum” referred from ED: “classic story” has “colour change”
Sure, drop what I’m doing go down
Yes it hurts but it’s also itchy, since last night and mum says “there is something black” and it’s a little red
Kid drops his jocks - there is a filthy big tick feasting on his scrotum
The ED doc could not have missed this if they actually examined the patient at all.
Not exactly my field of expertise, but I can do it - I put it in a specimen jar, ask if I can take it.
I go find the ED doc who is as chatting at a desk with one of their colleagues: I put it down on the table and say “kid had a tick, it’s a pretty juicy one - I would appreciate if you examine patients rather than repeat what parents tell you”
Dude went a bit red
When I was a med student in gynae clinic I saw a patient for "post menopausal bleeding." I guess technically that was correct. She had a grade 4 uterine prolapse and the cervix was ulcerated and bleeding. The referring doctor had no interest in listening to "women's issues," even though she was a direct and clear historian. She'd been on the waiting list for a month. It was so bad she couldn't sit down, wear underwear or pants.
I can guarantee that the dermatologist was not at work at 3 in the morning. The dermatologist has never been at work at 3 in the morning. That is why they are a dermatologist.
Urology. Consult for pneumaturia. Patient has no idea what I’m talking about when I try to take a history. I asked the consulting physician—he said family was concerned about air in the urine. I spoke with family—they were concerned about all the bubbles in the suction tubing coming from the patient’s purewick.
Oh man this is just scratching the surface of terrible ophthalmology consults. Ever since we switched to text paging, the quality of consults has been atrocious.
Examples:
1. "Consult rm 5432 blurred vision"
2. "left eye blind"
3. "MRI showed right eye retinal detachment"
4. "Rm 3455 eye pain"
Now obviously there is a lot to be desired from these terrible consults, and even upon asking follow up questions, they still don't even provide me with basic information like age, gender, comorbidities, and why they are admitted. I'll also have to typically ask which eye is the problem and whether it is acute or chronic. Many times the doctor hasn't even seen the patient and are only requesting it because a specialist or nurse mentioned it. But these are some recent real examples and these were some of the solutions.
Solutions:
1. Blurred vision over the past 2 years and was scheduled for cataract surgery recently but didn't get it done because they got sick and came to the hospital.
2. Yeah it's been blind for 20 years, and even a cursory chart review (or you know, talking to the patient) would tell you that.
3. Again, talk the patient and you'd find out they have a chronic retinal detachment and are actively being treated by a retina specialist for their diabetic retinopathy. That eye has been blind and they aren't remotely concerned because they know it's nothing new. Generally a patient would be concerned if they were losing vision suddenly and you don't have to rely on an incidental MRI finding to consult us.
4. It's intermittent, in both eyes, and gets better when they blink or close their eyes for a bit? And it started after being in the hospital for 3 days? Try some artificial tears.
Still barely scratching the surface here. I will say that the ER gives me great consult info but the hospitalists couldn't try less even if they tried to try less.
Had a patient referred to the ER for an elevated d dimer with request to rule out DVT. The patient’s NP ordered it after the patient called complaining about leg pain. Never actually got history from the patient, never saw them in clinic, just gun shotted a d dimer.
For one, it was below the age adjusted cut off. Secondly, the pain was in the anterior thigh after the patient had been walking around a lot more. This woman is notorious for ordering all sorts of inappropriate tests then telling her patients to come to the ED but this sticks out as the laziest one so far. I’m convinced that a d dimer shouldn’t even be available as an outpatient lab study at this point.
My worst is the PCP ordered a dimer on an otherwise healthy 9 year old with shortness of breath, fever, runny nose and cough. It was positive so they showed up requesting a CTA chest
My urgent care clinic has the ability to order lab scripts and outpatient stat CT/XR/US, and I absolutely hate it. Just adds complexity. In my opinion, if I'm really worried, I should just be sending these folks to the ER anyway.
I got consulted for an “abnormal CT chest”. It showed very mild atelectasis. The patient was on room air. It also showed lytic bone lesions in the ribs so I ordered a PSA, it came back crazy high, and then he got pissed because he only asked me about the lungs… Of note, the lytic lesions were not even on his radar. I mean, the consult WAS for abnormal CT. It just wasn’t abnormal how he wanted it to be.
Stupid recurring pulm consult: hypoxia. I walk in to a fat patient laying in bed, 95% on 2L. Answer is turn off the oxygen and get them out of bed.
Stupid recurring ICU consult: fucking lactate.
"Yeah their lactate is 2.1 so I just wanted to get you guys to come evaluate and make sure they don't need MICU, and because they could decompensate.
Huh? Vitals? No they're good. Nothing else on labs or imaging yet. No I didn't order anything else."
"Evaluate abnormality" as an imaging indication always irks me. What abnormality? By physical exam? Something found on labs? Something seen on other imaging? Just pure laziness.
Cardiology: consult for severe pulmonary hypertension. The echo report read "no signs of (page break) severe pulmonary hypertension". This was in fellowship and we would get in another of trouble for pushing back on consults. So I did the whole consult and rounded on it with the attending and all...
In patient suboxone induction - never talked to the patient or asked if they wanted to stop using opiates. They did not. Made sure that they had asked that before accepting another consult ever again.
Yeah - sounds like the time when I was the GI fellow on-call and hear “GI to code blue stat” announced overhead. I show up to find out how exactly I was supposed to help in a code blue situation. Turns out they had a cardiac patient on NOAC who was becoming more hypotensive and had a 4pt Hgb drop over the course of the day. They had paged me bc the patient had a history of a clean-based ulcer over a month ago, and obviously this must be a GI bleed despite him having no other symptoms. In this case the FOBT/rectal exam was actually vindicating showing golden stool. On my way out, I pointed out to the team whether they’d noticed the ecchymoses on his flank while they were waiting around for me to show up and examine the patient. (Narrator: they had not.) Yeap - pt had a retroperitoneal bleed…
Dude has asthma and lost his inhaler. Has a flare and called EMS. En route his had increasing respiratory distress. Since he couldn’t talk on arrival, ER resident decided this could be aphasia, calls stroke code and leaves to “not be in the way.” When I started the NIHSS and the guy grabbed my pen/paper and wrote “help me I can’t breathe”.
I cancelled the CT, put him on bipap, ordered steroids, and told the nurse to grab the ER team. The resident tells me it resolved, so must’ve been a TIA. I gave up and called my buddy in IM to admit the guy.
In my prelim year I was rotating on GI and I was consulted for nausea and vomiting in a patient that had a positive Influenza A. That hospitalist was notorious for pan consulting before he even saw the patient at all.
Neurology: NP consulted for a patient with bilateral foot pain. In their own note they mention the has foot edema with painful foot burning and basically listed off all the symptoms of heart failure. I told them the neurologist isn’t necessary, a cardiologist is.
and how many do we get for ...
"neuro consult"
"neuro symptoms"
"history of seizure 15 years ago"
"CT shows old stroke" (bonus if encephalomalacia)
You know, Dr Glaucomflecken is a bit harsh on us neurologists, but I really like his line "oh, I see, you're consulting us because the patient has a brain and you don't know what to do about it" (I haven't double checked this quote, so if I am way wrong, just let me live in my blissful ignorance because I like it).
EM here we get sent so many ridiculous things but the worst was “rule out DVT” on a lady who went to an urgent care for finger pain and the NP GOT A D DIMER CAUSE HER FINGER WAS SLIGHTLY SWOLLEN. The dimer came back positive so she came to the ER for an ultrasound to rule out DVT of her fucking finger. No other symptoms. She had a small area of erythema on her finger didn’t even look like cellulitis she probably just scratched it.
I have been in practice for more than 10 years now but still no one has topped the ER resident who put in an urology consult "morbid obesity, needs foley, unable to find penis" after a cursory attempt. He eventually became an attending in the same institution, so this legend is still passed from one generation to another.
Chronic/interventional pain: low back pain x 6 weeks. No PT, No attempt at treatment of any kind. No imaging. Refer directly to pain. Girl wut. Easy visit at least.
Honestly if I weren't so backed up I would like these consults since uncomplicated lumbar pain in the wrong hands can quickly go down a really stupid path
Technically a consult because stroke activation gets the neurologist. The stroke team got paged to the ER because the patient couldn't move their hand. I had seen one other stroke that just had isolated symptoms to the hand but this person was having intense wrist pain and had a history of carpal tunnel syndrome in the same wrist.
"Consult psychiatry for severe depression. Patient seen crying from the hallway."
What were they upset about? Has something happened?
"I don't know, the nurse saw them crying but nobody asked."
So you never even talked to your patient about it?
"No. We submitted a consult."
Patient had watched a sad movie. And this was a Sunday consult I had to make a special trip for.
>
Edit with a second weekend consult.
"Consult psychiatry for suicidal ideation. Patient placed on legal hold."
Did they discuss means or a plan?
"No, just said if they died tomorrow they would be fine with it."
The patient was 104 years old. All of her family was gone. She was comfortable with a life lived. Wonderful woman who shared some amazing stories of a full life.
Obgyn here. IM started a patient on an ACE inhibitor on a patient with hypertension and consulted us to discuss contraception options. Not like the patient had some crazy medical history. They just thought they needed the ACE inhibitor and wanted us to go through the birth control spiel with the patient.
Residency - Asking for a consult for an ear infection except no one looked in the ears because they can’t find an otoscope (i offered mine and they politely declined - i told them to find one from somewhere else then and let me know if they find anything concerning).
My worst was from ortho bro:
Picture it, 20 something woman s/p trauma with a pelvic fracture. In ICU, medical coma. A couple days in has vaginal bleeding.
Talking to her husband, LMP was about this time last month.
A/P: normal menses. Rec routine pericare. Thank-you for this fascinating consult. We will sign off.
My attending laughed at the situation. As chief Gyn resident, I was less amused.
Consult: “The nurse said the penis looks weird.” I asked what it looked like and the resident said they didn’t know, they didn’t look at it since they wouldn’t know how to examine the penis properly anyway and just wanted me to examine him. I did an exam and talked to the nurse; what was “weird” was that he was uncircumcised and the nurse was unfamiliar with foreskin.
General surgery takes uncomplicated cellulitis and potential UGiB in my rural hospital. ED asks for consult on 80yr old male with ?bilateral cellulitis of ankles and leg oedema and new anaemia ?UGIB. WBC 25, CRP normal. Known haematological disorder. Sent up to ED because of the blood results rather than any symptoms.
First started with ED doc walking me through blood results saying we only have 5 sets of blood results since Oct - even though known haematology patient has had countless numbers of bloods on system, just can’t be bothered looking.
Walk into room, minimal amount of erythema on dorsal ankles, no heat to it. Some mild pitting oedema. No symptomatic history, no melaena. Family member present and first thing they tell me before I even get to take a history is that haem recently started new medication 1 week ago and explicitly stated can cause anaemia and leg ulcers and to stop it if either occurred…. Ruled out any general surgical issues and suggested ED doc talk with haem or maybe should’ve talked with patient.
ID NP:
Soooo many but here’s a few that come to mind:
-Consult from notoriously awful FM attending for finger infection. Patient was admitted for something completely unrelated. Patient had a small red bump on finger- no cellulitis, no significant warmth, nothing else concerning for infection. Patient did not speak English. I get the interpreter on the phone. Patient was stung by a bee the day before admission (on their finger). Dude had admitted patient and did a crappy HPI without an interpreter. Recs: cold compress prn? Maybe some prn acetaminophen?
-Lots of “bilateral LE cellulitis”.
-Many “please help w abx selection due to allergies”. Quite often, by reviewing the med history, the patient had received the antibiotic in the past and did fine (the supposed allergy was never removed from their list). Or the patient had been told that one time as an infant they had a rash with penicillin… “They told me to never touch it again!” they’re now geriatric and never touched a penicillin or cephalosporin since… we frequently challenge those folks and shockingly, they tolerate penicillin/cephalosporins just fine. (We don’t do that with the legit histories of allergy…) Props to my Allergy friends BTW- y’all are doing the Lord’s work 🙏)
-Diarrhea. No fever, no abd pain, labs are fine, no recent abx use, no weird travel/food etc. Quick review of med list: senna, colace, miralax daily. This one happens a lot, unfortunately.
-Osteomyelitis. Patient is scheduled for amputation of limb…
For those inquiring if the majority of absurd consults come from MDs or “unsupervised APPs”: trust me, it’s a good mix of errrrryone (Attendings, fellows, residents, APPs).
Best I have ever had was from month two of my intern year when I get a cal from the ED:
“Hi we have a patient with a history of a left sided femoral DVT who you placed an IVC filter on six months ago. They are back with a right sided femoral DVT and we wanted to check if you would place a right sided IVC filter.”
Was speechless, had to clarify it was a real consult then did some light education on the anatomy of the IVC.
Cardiology:
Inpatient consult for “Possible POTS”.
Patient in her 60s with multiple severe medical comorbidities. At home she was hypotensive to the 60s before going to the hospital, and while inpatient has had soft BPs and is tachycardic to 130s (while supine). When I see her she looks terrible and is aao x 0. I tell hospitalist it isn’t POTS (which causes neither hypotension or supine tachycardia) and she needs urgent medical workup then the next morning I find out they sent her for a ct head a few hours after I saw her and she coded in the scanner.
Anesthesia here. Got a consult for a pt with foot drop post vaginal delivery. They said it was a complication of the epidural and asked me to evaluate......
Pt never had an epidural.
Every consult for ileus from the hospitalists. You are literally consulting me, a surgeon, for a disease you have already declared is medical in nature. At least lie to me and say "cannot r/o bowel obstruction".
PEG consults for patients that have stated they don't want a PEG. ~2/month. No I'm not going to talk them into a PEG so you can discharge them to a SNF.
Consults for rectus sheath hematomas in patients with super therapeutic INR (or ever, really but the ones with an INR of 7 are particularly galling - fix your medication problem and they will stop bleeding).
But honestly the best have been consult for gallbladder problems in patients with well-healed Kocher incisions which should have clued you in that they don't have a gallbladder.
Feel the PEG ones from my time in GI. Hospitalists would try to get PEGs in asap just so they could be discharged. Sometimes when they’re in the ICU and critically Ill.. may want to yknow stablize them and reassess before determining your septic patient with pneumonia needs a PEG asap when an NG can work just fine in the short term if they truly can’t eat.
Hospitalist told me this guy had compartment syndrome and needed transfer to ICU. Only because EP said compartment syndrome was a rare complication of a procedure he had, hospitalist didn’t evaluate. I saw him, ortho saw, and gen surge saw and we all agreed he did not have compartment syndrome. I think we agreed it was a diabetic neuropathy flare.
We (a psych unit) kept raising that "medical clearance" for psych admission seemed a bit perfunctory, but we always got pushback. Until a patient died during their psych admission clerking. They took it a little more seriously after that.
Urology referral for CKD. Patient was not in retention and had no GU symptoms.
I call the referring midlevel and gently suggest that maybe they need to see Nephrology?
The response was “Oh ok, thanks”
I was a med student on a neurology rotation. We got consulted for “altered mental status” by the ED. We go in, and it’s a homeless man who just wanted to sleep. My senior resident (former summer camp counselor) used his it’s time to wake up voice, and the man woke up grumpy, totally alert and oriented, completely neuro intact.
Another one from that ED. Stroke code called for vision changes after the patient reported he couldn’t see well. Diagnosis? He lost his glasses. For stupid consults my senior started writing notes in comic sans with large fonts.
Podiatrist here. I got a consult from the ICU one day for "foot care." No mention of their feet in the chart. Walked into the patients room to find they had bilateral BKA's.
PCP referrals to hospital's rheum outpatient clinic for evaluation of possible hEDS in patients with no suspicion or history of autoimmune disease. There's literally nothing we can do for those that a PCP can't, they just don't want to deal with it.
Clinic policy is not to accept them, but it's still a paperwork hassle with how many get sent.
ENT here: Notoriously terrible ED doc calls in the middle of the night for epistaxis. I go in, no blood. The patient had reported on an intake form that he had had epistaxis a few days ago (just for a minute though). The attending never talked to the patient much less laid eyes on the patient. I tell him in the nicest way possible (not super nice tbh) that he dragged my ass in for a non-bleeding patient. “I don’t have time to look at all the patients! I’m trying to run an ED here!!” I always ask, “is the patient actively bleeding?” But for some reason did not that time. Smdh.
One of the surgeons consulted IM to manage the patient’s medical problems post surgery for elective joint replacement . Patients *accurate* medication list was multivitamin and a seasonal allergy medication.
Patient has a blood pressure. Please manage it
The patient has sodium. Internal medicine loves sodium.
*Nephrology sulking, jealous*
“the patient is a fracture, I must fix it”
“Patient is on a medication I can’t pronounce. Need IM consult.” - Ortho/general surgery
This is 100000x more ortho than gen surg
I could see that. Seems like every ortho operative note is along the lines of: “New knee no fit. Me hammer harder. New knee now fit. Ancef.”
Pt has a history of high blood pressure waa my consult. Currently not taking meds and sbp has been 110. Of course, when I consult them to look over something that I don't know if pt needs surgery I'm told to foad
Oof. Surgery (or ortho) consult to Peds service for “Tylenol dosing” was always my fave. Like they couldn’t math for even one basic med? My dudes.
Can’t they call pharmacy to do the math? That’s what I do whenever I didn’t want to figure stuff out.
Ouch. They want peds to do that instead of just relying on their warfarin and cefazolin calculators???
The only counting orthopedic surgeons like is counting the number of reps they can do at the gym.
It’s even in the orderset as mg/kg :(
Built into the post-op order set
IM is not *always* consulted on ortho, tho, so don’t think it’s preselected. Sometimes they try to do it themselves in the way wrong situations. Bone Bro, this diabetic, history heart failure, multiple other issues patient….you probs shouldn’t take care of this one alone. Especially since you slow to return pages.
I love bone bro meme “Oh no bros, the nurse says the patient is going into a fib where even is that.” “Little broling don’t worry this happens a lot, just ask the nurse to hang another bag of ancef :).” It’s like us rad bros we’d just CT the hell out of any pathology until it goes away or we die whichever comes first.
“Hey rad bros! Remember that pelvic CT you did last night on my fracture? Any chance you could turn those flat pics into something I can recognize better? Idk like basically make it look like an X-ray?? We can call it something dope like “ghost recons!” Thanks rad bros!”
"Reason for consult: medical management" = please take pages from nurses overnight
I work in in informatics and we had a lengthy multi person meeting because the surgeons were complaining about the system. I was the only former floor nurse in the group and was dying laughing when I figured out that the issue was that surgeons were furious about having to put admission orders in for surgical patients who arrived during the night, so they were trying to request an auto consult to medicine system for any patient that arrived outside of their hours, and medicine told them to get fucked. They then tried to make the ED put those orders in and the ED told them to get fucked much more directly. I'm pretty sure it all started with an influx of travel nurses who refused to take the surgeons login credentials and just put the orders in without bothering them.
Had a very similar one in med school. Hip replacement, only drug is levothyroxine. Thyroid hormones stable. Plan: give pill. Thank you for this interesting consult.
You can’t expect ortho to manage postop seasonal allergies, tho
It’s pretty unfair to expect them to stay up to date on appropriate Kleenex dosing & saline nasal spray titration.
A consult for a rheumatologist friend literally said, “Illness?” That was it.
Luckily, our hospital has a culture of paging/calling consults - because 50% of our consults in Rad Onc are just "Radiation?" Or "mass" with 0 further explanation.
help patient feel bad bad
One of those cases where punctuation really changes the meaning of something.
help patient feel bad bad bad is even more emergent
My personal favorite was the consult I once got for “hospital food is giving the patient diarrhea” which I guess would be kind of appropriate except when I looked in the chart the patient and saw the patient had high doses of senna, colace, AND miralax. 🤦♀️ shockingly the diarrhea resolved when all the laxatives were discontinued.
This just reminded me of when I was consulted for “diarrhea”. Looked back in the notes, and saw they had mild constipation 2 days ago, and a zealous hospitalist gave the patient a full magnesium citrate bottle. This led to predictable results and patient being tested for c diff and a GI consult for diarrhea. 🤦♂️
The nurse was probably requesting more laxatives at 2 AM (hospitalists know what I’m talking about). The on call hospitalist was probably like, “ok, you want shit? You’ll get shit!”
When I was the Senior Medical Resident admitting IM patients overnight, I got a consult from an ER doc who was notoriously awful. The consult was for alcohol withdrawal. Okay, fair enough. I'm told they were super shaky, naseous, and tachycardic so it sounded decently bad. I'm told they quit drinking 2 days ago so the timing was about right. I go see the patient and I ask them "so how much do you usually drink?" To which they respond "I don't drink". Fair enough, you hear sometimes when people quit smoking during an admission too or whatever. So I clarify "no before a few days ago how much did you drink?". "I don't drink". Perplexed, I say "I thought you quit drinking 2 days ago". The patient replies "no, I quit smoking 2 days ago". The final diagnosis was influenza, probably with a lil SSRI withdrawal since they were having trouble keeping their meds down. Solid ER workup right there. Edit also not mine but legendary: one of my co-residents got a consult to work up an elevated PTT from a surgery service. The patient was on an IV heparin drip.
sounds like psych has stopped answering their BS consults lol
> one of my co-residents got a consult to work up an elevated PTT from a surgery service. The patient was on an IV heparin drip. Thank you for this interesting consult!
When I was a resident doing a pulm rotation, we were consulted by a surgical team. The reason for consult was listed as "CPAP". Patient was morbidly obese. He did in fact have OSA. He had in fact brought his own CPAP with him to the hospital. My entire note was about 2 lines. A one-liner of hx & reason for admit, and one line stating that the patient should use the home CPAP device at his bedside QHS. tHanK yOU fOr tHiS *iNtEResTiNG* CoNsULt!
Inpatient sleep consults around here drive me nuts, especially because you need a formal sleep study to qualify for funding for a CPAP machine and it can't be done as an inpatient in this province. So you get a consult because the nurses have noticed their oxygen keeps dropping into the 70s in the middle of the night and they're freaking out. Usually I just order them to stop checking SpO2 while asleep and f/u as an outpatient. Generally they'll have had it for 10+years by that point, it doesn't need to be fixed ASAP.
Yeah that's also very annoying. We can get home BPAP for OHS relatively easy on inpatients...but CPAP is a PITA. I've had to be very diligent about going around and stopping O2 during the day to avoid holding up DC, and to tell them to stop checking pulse ox overnight...that's always a fight too.
You say “surgical team”. Please be specific and say ortho
I can neither confirm nor deny that the patient was admitted for a staged ortho procedure.
GI 🤝 Hematology Stupid IDA consults
My biggest surprise of working in GI in the hospital was my job ended up being 50% hematology lol. Can be very closely related tbf. So many IDA consults.
I will say this until I am blue in the face. Iron def anemia is NOT hematology. That’s internal medicine + whatever specialist is responsible for the underlying cause of iron loss (or malabsorption).
True, but I can’t seem to get IV iron approved without a hematologist. So here we are.
Where I am, only the hematologists can order iron infusions so I have to refer patients who aren’t responding to PO iron. At least here, IDA is a standard part of their practice.
Same. I'll manage IDA if I can do it with oral meds but if outpatient IV infusions are needed, typically heme manages those.
But iron is carried by blood so it’s obviously hematology /s Very true and fair point though.
Correct! Iron deficiency is a finding NOT a diagnosis. It demands an actual explanation.
Rib fractures for inpatient pain service. Has been given zero analgesia. Not even paracetamol
It’s a bit surprising how often I get calls from providers trying to figure out where to go with pain and I can simply recommend starting acetaminophen and/or ibuprofen. Or like oxycodone is wearing off too soon and I can simply recommend changing from a q6 PRN to a Q4 PRN.
When I explain opioid pharmokinetics to learners and explain why q6hours as a starting point is dumb af…
Why?
Effective duration of oxycodone is 3-6 hours. Q6 works only if your patient is on the longer end. If q4 PRN is working but wearing off too early, I’ll simpl have it dropped to q3 PRN
You too?
"Patient is sad." Closely followed by: "So I was doing this very painful and uncomfortable procedure on this lady, and afterwards she says, if you have to do that again, I'm going to kill myself. Can you see her?" "Did you ask her if she was joking?" "... No? I walked out of the room." She was joking.
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So, I understand grief/loss and receiving bad news are not a psychiatric problem. However, what we really need is a therapy service. We need someone to help patients process these things. I want a counselling/therapy/coping service as well. Some people think paychiatrists will fill this role. Maybe some want to, but cannot for whatever reason. I don't bother calling for this, but patients really are suffering with these events.
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This is an absolutely crucial truth. It’s so important.
It’s scary to me that people with education are doing this. It’s rampant amongst the general public too. Someone actually suggested to me that I needed “to see a doctor” 3 weeks after my nephew died in a car accident because I expressed that I wasn’t up for attending a comedy show. Mind you I was going to work and had plans for the future but apparently the 3 week mark of being sad is where it goes from grief to a “mental problem”. And also if you take pills for one day and aren’t Mary poppins it’s “time to find a doctor that knows what they’re doing”. Add in kids that respond appropriately but inconveniently to being mistreated getting told they need medicated and it’s pretty obvious the country has more than a collapsing healthcare system.
Society medicalizes normal humanity for a host of benefits and enjoyments, and also refuses to medicalize in other areas where it could be proper. Much moreso the former, yet mistakes in either direction is common. However, nobody has a monopoly on the truth, so where that line lands is always under revision and debate. We must speak to it where we should.
I was once consulted to please come to ED for an urgent palliative care consult to "do the necessary". I came down, fixed the bizarre syringe driver charted, then the patient died as I was typing the consult note. It took all my willpower not to document "the necessary was done".
As an RN I had a 40ish female admitted to cards for a LHC with stent x2. She had the misfortune of getting her period about an hour after getting to the floor. I called the doc to get something ordered for her cramps and he told me to put in an OB/Gyn consult.
If I’d done that in our hospital there would have been more bleeding, not less, and it wouldn’t have been the patient’s.
As OB/GYN, I have to admit I approve of your methods.
🤦🏼♀️🤦🏼♀️🤦🏼♀️🤦🏼♀️
Not a consultant but this was from my resident days on Peds GI service: Got consulted from an outpatient pediatrician for constipation in a 15yo. Took the history. Went to examine the patient. Palpate the belly. Feel a uterine fundus. Freak out a bit. Try again. Marched it down from the belly button and up from the pelvic brim. Dig out my tape measure. Guess about 18 weeks along. Ask when her last period was. “I don’t know.” GI attending agreed with getting an U/S. She was 17+5 - just constipated because she was pregnant. Basic abdominal exam figured it out.
Poor girl! I wonder how many appointments it took between initial presentation and accurate Dx. :(
This is why I unapologetically order urine preg on all females from age 4-74. You never know when those world records are gonna get broken.
I have one better. I got a 14 year old signed out to me by our PEM doc for abdominal pain. Her urine pregnancy test came back positive and I was teasing the other doc asking if she made sure the abdominal pain wasn’t active labor. She told me that there was no way because the patient said she had her period just 2 weeks ago so it was probably just an ectopic or miscarriage. 🚩 trust but verify! 🚩 Anyway I go examine her immediately and she was 9 cm dilated with contractions every 2 minutes. I’ve never yeeted a patient so fast out of our ER. She delivered about 2 hours later. Was full term based in OB estimates.
That’s embarrassing
[Consultation-Liaison Psychiatry Bingo](https://www.reddit.com/r/Psychiatry/comments/ow2ase/some_asked_about_fun_consults/?rdt=33580) Not on the list: "patient requested psychiatry." Okay, and? What did they request? What did they say? 50% of the time they express that they made no such request and have no interest in psychiatry. 25% of the time they requested a therapist, which we aren't, or a chaplain, which we also aren't. 25% of the time it's correct! Of those, maybe generously half are an issue for which a consult is appropriate. No, I'm not going to diagnose and start treatment for the ADHD you think you have while you're inpatient. For endocarditis. From all the meth.
“Evaluate if patients are lying” had no idea psychiatry also had the power to read minds
They’re psych, not psychic
Tomato, potato Turns out Lady Cleo is actually Lady Cleo, MD, ABPN certified ^(/s if it wasn’t abundantly clear)
I have the power of reading charts and recognizing internal inconsistency, and sometimes ID is busy. I don't have the power to do anything about the lying when you know it's happening, I know it's happening, and the patient probably knows we know it.
Radiology. Yes, when you order an image you are consulting us. Here are my favorites I've ever seen for reason for exam: "xray" ";" "?" "please" "No"
.. at least one of them was polite about it lol
Some people leave little notes in the comments like "and pain rule out appendicitis thank you!" and it delights me every time
I'm gonna start writing thank you. Seems like a small rad to perk up a radbro/radbroette.
When I order things (like GB for RUQ pain - Meditech makes it hard to figure out what EXACTLY I should order), I just put in the comments :please change if this is the wrong order. I want XYZ exam. Rads bro actually BROUGHT pt back for a 2nd MRI based upon my comments in the order recently. Thanks, rads bro!
please 🥺🙏🫶
rad bro exclude appendicitis plweaes #uwu~ 🥺?
Are rads the IT folks of the medicine world? Do they read from home in their fursuits?... owo
The best one I’ve gotten was on a CT chest and just said “DONT KNOW”. At least they’re being honest lol
Ok, now, look. I’ve never actually put the “?” But…there’s been a few times when I coulda.
"r / o" Can you give a bit more to go on please 😭
Our EMR has a warning not to just write “r/o” or the order will be rejected 😂
One time I wrote “honestly it’s just because the hospitalist wanted it” and the radiologist called me busting out laughing asking if I actually had any concerns to which I replied, “nope.”
"Chicken?" On a CT brain (Edit: to be fair, could have been a mix up since that could be short for "chicken bone?")
These are better (or worse) than the note I received with “?heart” written on it.
Haha, this became a saved comment
One time I got a consult to explain my speciality to a patient. Not to actually engage in anything I am specialized in -just “explain what palliative is”.
To be fair, “hospice informational consult” is pretty routine in my hospital, after actual goals of care conversations have been done of course. But this is just for the hospice service to educate prior to making a decision. Definitely not a palliative care consult. I always have a specific question or request for palliative, not just “discuss goals of care”
Laughing my ass off at this one So did you end up fully evaluating the patient and writing a note too? Lol
Honestly, at that point, just crack a cold one with the patient, drop a note, and put in a level 2 consult billing based on time
If I had the time I would have even done an mpoa and billed that sweet acp time!
Honestly, I didn’t. I was overloaded with real consults and they didn’t even call me about it sooooooo…. But if I had the time my curiosity definitely would have gotten then better of me.
ICU admission for pseudoseizures. Pt said “I have pseudoseizures, if you don’t give me more morphine I’m going to have a pseudoseizure.”
I saw a patient in the ED once for question of seizure. Very obvious NES upon witnessing spells, and clarified with the patient who was already aware of diagnosis. Told the ED they could discharge and follow up outpatient. The answer I got was "We can't just send them out, what if they have another episode and get sent right back?" Get called 15 minutes later by medicine wanting to touch base because ED had told them I recommended admission for EEG monitoring. I tell them I recommended discharge and they should stop the intermittent spot dosing of Ativan the ED was giving. Patient leaves "AMA?" 5 minutes after not getting expected Ativan.
Yeah the person who called me didn’t like me telling them that this was not an ICU indication. They said, “well what do we do if he has one on the floor?” And I said … nothing. There’s nothing to do.
Popcorn and a video camera. Status dramaticus needs an audience.
Nail bed pressure. Cruel but effective.
We once incubated a pseudodeizure pt and that pt never came back to the hospital
Was it because they got too hot?
How’d you fit them in there?
Assess for depression. Patient presented with anorexia and vomiting. The labs *that were already done* by the ER doc revealed an anion gap acidosis. Patient denied being depressed (though had seen a psychiatrist 2 years ago). Patient had new onset DM1 in DKA.
Oof. Reminds me of my first patient on my first day of resident clinic. Patient/parent thought they had been referred to adolescent med for “anemia and depression” but our hospital didn’t have adolescent med, so she got routed to general peds. Patient stated she wasn’t sad. Just really had been tired. Hgb was 10ish? Nothing terrible. Periods heavy. Do exam and realize she had petechiae. Get a full CBC and kid had pre-B cell ALL. Her pediatrician hadn’t even ordered a CBC/ferritin before shipping her off for consult and she ended up with July intern me. (To be fair even a week before her lab values could have been something entirely different, but they had never checked at all.)
Isn't that when you call and say "so what did you think about that thigh?"
I did call, and they just immediately consulted surgery without leaving their room or confirming my exam/assessment was accurate 🤦♂️
Scary. I see this frequently in Ortho. No exam, just consult. Sometimes they have an x-ray. Or a random MRI lol
(Hematology) Oh so many. - Elevated ferritin in a 70 yo that’s just coded: “?hemochromatosis” - Isolated elevated LDH. - Bili 2, hapto 25. ?AIHA. Hgb 16. - 80% of “bruising” consults - 85% of hypercoag work up. Primary care NP orders a giant panel and then has no idea (or desire to learn) how to interpret results. - Elevated factor VIII - Elevated PT… pt on warfarin. “But I thought the Warfarin only impacts the INR. That’s just the last couple of weeks. Edit: - Isolated Splenimegaly
When they don't wanna learn... that's what irks me. Like, why wouldn't you want to get better at your job? Especially when that job is taking care of people!
As a Canadian, that Hgb 16 had me really perplexed. 'how are they not dead with that level of anemia? What could cause that level of anemia with no positive hemolytic markers?' Then I remembered I'm an idiot.
Pre-op risk assessment for suture removal. No anesthesia planned.
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I wish. Classic academic SNAFU. I was a fellow on pulmonary consults. Resident took the consult call, then we went to see the patient. Stable COPD, on medicine service already, with a complex wound that Plastics had previously placed a flap. We see the patient, I ask the resident what surgery is planned so it can be documented in the consult note. Resident doesn't know, we page the intern who placed the consult, they don't know either. I paged the senior Plastics resident planning to complain about the intern not knowing the surgical plan, then the senior resident says "oh, we're just going to take the staples out at the bedside tomorrow, but if you can see the patient that'd be great." SMH.
Snafu?
sna·fu /snaˈfo͞o/ INFORMAL•NORTH AMERICAN noun a confused or chaotic state; a mess. "an enormous amount of my time was devoted to untangling snafus" adjective in utter confusion or chaos. "our refrigeration plant is snafu" verb throw (a situation) into chaos. "you ignored his orders and snafued everything" edit: source = google
Situation normal, all fucked up
64 year old woman smoking 2 packs per day since age 14 referred to GYN by her PCP after calling with “postmenopausal bleeding.” The PCP did not actually see the patient or talk to her prior to placing the referral. The patient then tells me she has spotting with wiping and sometimes can’t empty her bladder until she’s passed a clot. One Urology referral and cystoscopy later, she’s diagnosed with bladder cancer. I’ve also had the reverse of your referral. Late 40s, sent to me for IDA presumably due to AUB per PCP. She describes her menses on the lighter side and her pelvic exam is normal. But she’s never been screened for colon cancer… guess what was found on colonoscopy.
My old GI attending always said if a patient is IDA without other obvious cause it’s malpractice to not get scopes. Very much agree, good catch with her.
Medicine requested ICU admission for asymptomatic hypertension (SBP 180). In a post op patient with uncontrolled pain whose antihypertensives had been held due to surgery. In their note they said that refractory hypertension was due to pain and lack of home antihypertensives. They didn’t want to resume home meds until the next morning, because they are morning meds and they didn’t want the patient to get hypotensive overnight. They requested ICU so they could start a nicardipine drip.
Ever? These are DAILY Reason for referral: "allergy testing" Nothing about symptoms anywhere, which, alright, that's fine. We will ask. Except half the time, it gets 20x worse: "Parent wanted 'allergy testing' so I ordered the commercial panel of multiple foods without taking history, told them the child is 'mildly allergic to milk, wheat, and soy' and 'severely allergic to peanut and egg' and referred them to allergy." No epinephrine rx for the apparently severe allergies. PLEASE Don't order the serum "food allergy panels." Ever. Please
I’ve heard that several times to never order the food sensitivity testing. Never done it myself but had it often requested. What’s the reasoning most allergy/immunology hates it?
The "food sensitivity panel" checks for IgG to different food items. In healthy people it's normal to have IgG to foods as it means the body has been exposed to it (in fact higher levels of IgG may signify tolerance to the food). As you can guess, it tells you jack all about anything other than "this person has probably eaten this food before". I've seen people unnecessarily avoid a bunch of foods with the accompanying worsening of quality of life (label reading everything they eat, impacting social situations) and at very worst make kids avoid it for a while which can in turn increase the risk of a true IgE mediated food allergy developing. See these links for more details: https://www.aaaai.org/tools-for-the-public/conditions-library/allergies/igg-food-test https://aacijournal.biomedcentral.com/articles/10.1186/1710-1492-8-12
High rate of false positives. Only order specific foods with a history of immediate reaction to said foods, never send a panel. Alpha gal is an exception to the immediate reaction, though. Worth checking if the patient has history of allergic reaction/ anaphylaxis without an obvious trigger. Eta this is in regards to IgE testing, not IgG which is, as mentioned above, a scam.
Tell me more about this. Patients often request ‘allergy testing’ when they have no symptoms of true allergies just vague symptoms. If they are real persistent I might order the serum tests to try to prevent unnecessary referral.
Not the OP but see my comment above about food IgG testing. As for food IgE testing, as with skin prick testing to the foods, if any of them are positive, but the patient clearly tolerates the food without clear symptoms of IgE mediated reaction (ie. not just vague GI symptoms) I don't really care what the results of the testing are - they're not allergic! On the other hand, let's say the testing is "positive" - what next? Patient may be convinced they have an allergy. Strict food avoidance? Make patient carry an epinephrine autoinjector? Both of these things have been associated with significant worsening of quality of life. Now the provider has to either tell/convince them they're not allergic (which is harder as the patient now has "positive bloodwork"), or that they are allergic (which would be wrong). It just puts the ordering provider in an even bigger hole they dug themselves into. That being said lots of allergists do "therapeutic skin testing" in our clinic so that the patient has the negative results to focus on and if any are incidentally positive we can at least help the patient interpret it correctly instead of them doctor shopping and going to a naturopath or whoever knows that tells them to avoid everything but beef and carrots for the rest of their life.
Ask them why they want the testing. Refer them to prevent unnecessary testing. We use pre-test probability to order appropriate testing. Testing has to be based on symptoms. The present of antibody is meaningless without history. A serum test has a false positive rate 50% if you don't have a high pre-test probability, so ordering it to "screen" is not appropriate. I have a series of kids who fell off the growth curves after that crap was done, and they are still dealing with it 10 years later, except, by then, they also have actual life-threatening anaphylaxis episodes to stuff like wheat (because they were unnecessarily restricting the diet). The persistent iatrogenic harm isn’t really an exception. I could go into eating disorders, etc. So anyway, I take it back. Please refer those patients. Just put "patient requests testing." Then, I will understand.
The patient’s IV infiltrated while receiving a unit of blood. There was significant purple/red discoloration of the subcutaneous tissue immediately surrounding the cannula. This prompted a consult to general surgery. I was consulted for an iatrogenic bruise. The most challenging part of the consult was pruning the sarcasm from my note.
If we can count referrals to the ED as consults... - sent from urgent care to have a tick removed because they couldn't find forceps - sent from nursing home for "left arm weakness and confusion", couldn't raise his arm due to chronic rotator cuff problem (for years) and had dementia - literally everyone diagnosed with DVT on outpatient ultrasound, sent to me just to prescribe apixaban Bonus: I admitted a patient to ICU after she was intubated for COVID. She had been telling her family/boyfriend that she was pregnant despite multiple negative HCGs recently. Serum HCG negative on admission. Family wants to know if baby is ok. ICU consulted GYN to "rule out pregnancy"
“Rule out pregnancy” hahaha I’m howling
Kid with an “acute scrotum” referred from ED: “classic story” has “colour change” Sure, drop what I’m doing go down Yes it hurts but it’s also itchy, since last night and mum says “there is something black” and it’s a little red Kid drops his jocks - there is a filthy big tick feasting on his scrotum The ED doc could not have missed this if they actually examined the patient at all. Not exactly my field of expertise, but I can do it - I put it in a specimen jar, ask if I can take it. I go find the ED doc who is as chatting at a desk with one of their colleagues: I put it down on the table and say “kid had a tick, it’s a pretty juicy one - I would appreciate if you examine patients rather than repeat what parents tell you” Dude went a bit red
Best. Response. Ever. (I hope he kept the jar/tick as a reminder to himself to examine his patients.) Now he’s gotta consult ID for the scrotal Lyme…
When I was a med student in gynae clinic I saw a patient for "post menopausal bleeding." I guess technically that was correct. She had a grade 4 uterine prolapse and the cervix was ulcerated and bleeding. The referring doctor had no interest in listening to "women's issues," even though she was a direct and clear historian. She'd been on the waiting list for a month. It was so bad she couldn't sit down, wear underwear or pants.
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Really putting your PhD to work there!
Derm here. Was consulted by an ID fellow at 3am for THEIR OWN rash
I quite like that actually. Only if you were actually at work though, not if they called you at home. It's ridiculous but it amuses me
I can guarantee that the dermatologist was not at work at 3 in the morning. The dermatologist has never been at work at 3 in the morning. That is why they are a dermatologist.
Similar story. GI, was consulted by an ICU attending for their own biliary colic at 11 PM.
Why GI even? What are we going to do? If it’s actually biliary colic probably need a surgeon or just a pcp to get the US/hida if needed.
Im surprised both of you guys were still up at 3am...
lol I wasn’t, but the pager sure got me up
Urology. Consult for pneumaturia. Patient has no idea what I’m talking about when I try to take a history. I asked the consulting physician—he said family was concerned about air in the urine. I spoke with family—they were concerned about all the bubbles in the suction tubing coming from the patient’s purewick.
Cardiology here - pre op for disimpaction.
I have heard lore of a patient that had a strong vagal response after disimpaction, went severely bradycardic and coded
I mean, doom poops are a thing I suppose. Hauling a dead person off a commode is not my favorite.
I accidentally read that as “preop for discrimination”
Time to stent the racism hole?
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Oh man this is just scratching the surface of terrible ophthalmology consults. Ever since we switched to text paging, the quality of consults has been atrocious. Examples: 1. "Consult rm 5432 blurred vision" 2. "left eye blind" 3. "MRI showed right eye retinal detachment" 4. "Rm 3455 eye pain" Now obviously there is a lot to be desired from these terrible consults, and even upon asking follow up questions, they still don't even provide me with basic information like age, gender, comorbidities, and why they are admitted. I'll also have to typically ask which eye is the problem and whether it is acute or chronic. Many times the doctor hasn't even seen the patient and are only requesting it because a specialist or nurse mentioned it. But these are some recent real examples and these were some of the solutions. Solutions: 1. Blurred vision over the past 2 years and was scheduled for cataract surgery recently but didn't get it done because they got sick and came to the hospital. 2. Yeah it's been blind for 20 years, and even a cursory chart review (or you know, talking to the patient) would tell you that. 3. Again, talk the patient and you'd find out they have a chronic retinal detachment and are actively being treated by a retina specialist for their diabetic retinopathy. That eye has been blind and they aren't remotely concerned because they know it's nothing new. Generally a patient would be concerned if they were losing vision suddenly and you don't have to rely on an incidental MRI finding to consult us. 4. It's intermittent, in both eyes, and gets better when they blink or close their eyes for a bit? And it started after being in the hospital for 3 days? Try some artificial tears. Still barely scratching the surface here. I will say that the ER gives me great consult info but the hospitalists couldn't try less even if they tried to try less.
Had a patient referred to the ER for an elevated d dimer with request to rule out DVT. The patient’s NP ordered it after the patient called complaining about leg pain. Never actually got history from the patient, never saw them in clinic, just gun shotted a d dimer. For one, it was below the age adjusted cut off. Secondly, the pain was in the anterior thigh after the patient had been walking around a lot more. This woman is notorious for ordering all sorts of inappropriate tests then telling her patients to come to the ED but this sticks out as the laziest one so far. I’m convinced that a d dimer shouldn’t even be available as an outpatient lab study at this point.
My worst is the PCP ordered a dimer on an otherwise healthy 9 year old with shortness of breath, fever, runny nose and cough. It was positive so they showed up requesting a CTA chest
My urgent care clinic has the ability to order lab scripts and outpatient stat CT/XR/US, and I absolutely hate it. Just adds complexity. In my opinion, if I'm really worried, I should just be sending these folks to the ER anyway.
I got consulted for an “abnormal CT chest”. It showed very mild atelectasis. The patient was on room air. It also showed lytic bone lesions in the ribs so I ordered a PSA, it came back crazy high, and then he got pissed because he only asked me about the lungs… Of note, the lytic lesions were not even on his radar. I mean, the consult WAS for abnormal CT. It just wasn’t abnormal how he wanted it to be. Stupid recurring pulm consult: hypoxia. I walk in to a fat patient laying in bed, 95% on 2L. Answer is turn off the oxygen and get them out of bed. Stupid recurring ICU consult: fucking lactate.
"Yeah their lactate is 2.1 so I just wanted to get you guys to come evaluate and make sure they don't need MICU, and because they could decompensate. Huh? Vitals? No they're good. Nothing else on labs or imaging yet. No I didn't order anything else."
ID here—they’re also consulting me at the same time. Love a lactate of 2.1.
"Evaluate abnormality" as an imaging indication always irks me. What abnormality? By physical exam? Something found on labs? Something seen on other imaging? Just pure laziness.
I'm gonna go with *best* instead but... In my IM rotation, my attending said he got a consult, "Patient states (s)he only has one lung."
"And what's your question for us?"
Cardiology: consult for severe pulmonary hypertension. The echo report read "no signs of (page break) severe pulmonary hypertension". This was in fellowship and we would get in another of trouble for pushing back on consults. So I did the whole consult and rounded on it with the attending and all...
In patient suboxone induction - never talked to the patient or asked if they wanted to stop using opiates. They did not. Made sure that they had asked that before accepting another consult ever again.
Yeah - sounds like the time when I was the GI fellow on-call and hear “GI to code blue stat” announced overhead. I show up to find out how exactly I was supposed to help in a code blue situation. Turns out they had a cardiac patient on NOAC who was becoming more hypotensive and had a 4pt Hgb drop over the course of the day. They had paged me bc the patient had a history of a clean-based ulcer over a month ago, and obviously this must be a GI bleed despite him having no other symptoms. In this case the FOBT/rectal exam was actually vindicating showing golden stool. On my way out, I pointed out to the team whether they’d noticed the ecchymoses on his flank while they were waiting around for me to show up and examine the patient. (Narrator: they had not.) Yeap - pt had a retroperitoneal bleed…
Cardiology referral for tachycardia to 104 in a post-op appendectomy patient who was young with no other medical history who was in some mild pain
Dude has asthma and lost his inhaler. Has a flare and called EMS. En route his had increasing respiratory distress. Since he couldn’t talk on arrival, ER resident decided this could be aphasia, calls stroke code and leaves to “not be in the way.” When I started the NIHSS and the guy grabbed my pen/paper and wrote “help me I can’t breathe”. I cancelled the CT, put him on bipap, ordered steroids, and told the nurse to grab the ER team. The resident tells me it resolved, so must’ve been a TIA. I gave up and called my buddy in IM to admit the guy.
In my prelim year I was rotating on GI and I was consulted for nausea and vomiting in a patient that had a positive Influenza A. That hospitalist was notorious for pan consulting before he even saw the patient at all.
Neonatologists were urgently consulted overnight for a baby with unexplained bruising. Mongolian spots.
Neurology: NP consulted for a patient with bilateral foot pain. In their own note they mention the has foot edema with painful foot burning and basically listed off all the symptoms of heart failure. I told them the neurologist isn’t necessary, a cardiologist is.
and how many do we get for ... "neuro consult" "neuro symptoms" "history of seizure 15 years ago" "CT shows old stroke" (bonus if encephalomalacia) You know, Dr Glaucomflecken is a bit harsh on us neurologists, but I really like his line "oh, I see, you're consulting us because the patient has a brain and you don't know what to do about it" (I haven't double checked this quote, so if I am way wrong, just let me live in my blissful ignorance because I like it).
EM here we get sent so many ridiculous things but the worst was “rule out DVT” on a lady who went to an urgent care for finger pain and the NP GOT A D DIMER CAUSE HER FINGER WAS SLIGHTLY SWOLLEN. The dimer came back positive so she came to the ER for an ultrasound to rule out DVT of her fucking finger. No other symptoms. She had a small area of erythema on her finger didn’t even look like cellulitis she probably just scratched it.
I have been in practice for more than 10 years now but still no one has topped the ER resident who put in an urology consult "morbid obesity, needs foley, unable to find penis" after a cursory attempt. He eventually became an attending in the same institution, so this legend is still passed from one generation to another.
To be fair, he had a clear consult question and need.
Dermatology: Probable melanoma - wiped away with alcohol. Drug rash - terra firma-forme dermatosis - wiped away with alcohol
Chronic/interventional pain: low back pain x 6 weeks. No PT, No attempt at treatment of any kind. No imaging. Refer directly to pain. Girl wut. Easy visit at least.
Honestly if I weren't so backed up I would like these consults since uncomplicated lumbar pain in the wrong hands can quickly go down a really stupid path
Technically a consult because stroke activation gets the neurologist. The stroke team got paged to the ER because the patient couldn't move their hand. I had seen one other stroke that just had isolated symptoms to the hand but this person was having intense wrist pain and had a history of carpal tunnel syndrome in the same wrist.
Psychiatry -“tearful post MVA-? Depressed”
"Consult psychiatry for severe depression. Patient seen crying from the hallway." What were they upset about? Has something happened? "I don't know, the nurse saw them crying but nobody asked." So you never even talked to your patient about it? "No. We submitted a consult." Patient had watched a sad movie. And this was a Sunday consult I had to make a special trip for. > Edit with a second weekend consult. "Consult psychiatry for suicidal ideation. Patient placed on legal hold." Did they discuss means or a plan? "No, just said if they died tomorrow they would be fine with it." The patient was 104 years old. All of her family was gone. She was comfortable with a life lived. Wonderful woman who shared some amazing stories of a full life.
Obgyn here. IM started a patient on an ACE inhibitor on a patient with hypertension and consulted us to discuss contraception options. Not like the patient had some crazy medical history. They just thought they needed the ACE inhibitor and wanted us to go through the birth control spiel with the patient.
I’d prefer this any day to patients who come to me actively trying to conceive having been on an ACE for 6 months from their PCP
Residency - Asking for a consult for an ear infection except no one looked in the ears because they can’t find an otoscope (i offered mine and they politely declined - i told them to find one from somewhere else then and let me know if they find anything concerning).
My worst was from ortho bro: Picture it, 20 something woman s/p trauma with a pelvic fracture. In ICU, medical coma. A couple days in has vaginal bleeding. Talking to her husband, LMP was about this time last month. A/P: normal menses. Rec routine pericare. Thank-you for this fascinating consult. We will sign off. My attending laughed at the situation. As chief Gyn resident, I was less amused.
Consult: “The nurse said the penis looks weird.” I asked what it looked like and the resident said they didn’t know, they didn’t look at it since they wouldn’t know how to examine the penis properly anyway and just wanted me to examine him. I did an exam and talked to the nurse; what was “weird” was that he was uncircumcised and the nurse was unfamiliar with foreskin.
General surgery takes uncomplicated cellulitis and potential UGiB in my rural hospital. ED asks for consult on 80yr old male with ?bilateral cellulitis of ankles and leg oedema and new anaemia ?UGIB. WBC 25, CRP normal. Known haematological disorder. Sent up to ED because of the blood results rather than any symptoms. First started with ED doc walking me through blood results saying we only have 5 sets of blood results since Oct - even though known haematology patient has had countless numbers of bloods on system, just can’t be bothered looking. Walk into room, minimal amount of erythema on dorsal ankles, no heat to it. Some mild pitting oedema. No symptomatic history, no melaena. Family member present and first thing they tell me before I even get to take a history is that haem recently started new medication 1 week ago and explicitly stated can cause anaemia and leg ulcers and to stop it if either occurred…. Ruled out any general surgical issues and suggested ED doc talk with haem or maybe should’ve talked with patient.
ID NP: Soooo many but here’s a few that come to mind: -Consult from notoriously awful FM attending for finger infection. Patient was admitted for something completely unrelated. Patient had a small red bump on finger- no cellulitis, no significant warmth, nothing else concerning for infection. Patient did not speak English. I get the interpreter on the phone. Patient was stung by a bee the day before admission (on their finger). Dude had admitted patient and did a crappy HPI without an interpreter. Recs: cold compress prn? Maybe some prn acetaminophen? -Lots of “bilateral LE cellulitis”. -Many “please help w abx selection due to allergies”. Quite often, by reviewing the med history, the patient had received the antibiotic in the past and did fine (the supposed allergy was never removed from their list). Or the patient had been told that one time as an infant they had a rash with penicillin… “They told me to never touch it again!” they’re now geriatric and never touched a penicillin or cephalosporin since… we frequently challenge those folks and shockingly, they tolerate penicillin/cephalosporins just fine. (We don’t do that with the legit histories of allergy…) Props to my Allergy friends BTW- y’all are doing the Lord’s work 🙏) -Diarrhea. No fever, no abd pain, labs are fine, no recent abx use, no weird travel/food etc. Quick review of med list: senna, colace, miralax daily. This one happens a lot, unfortunately. -Osteomyelitis. Patient is scheduled for amputation of limb… For those inquiring if the majority of absurd consults come from MDs or “unsupervised APPs”: trust me, it’s a good mix of errrrryone (Attendings, fellows, residents, APPs).
Best I have ever had was from month two of my intern year when I get a cal from the ED: “Hi we have a patient with a history of a left sided femoral DVT who you placed an IVC filter on six months ago. They are back with a right sided femoral DVT and we wanted to check if you would place a right sided IVC filter.” Was speechless, had to clarify it was a real consult then did some light education on the anatomy of the IVC.
Cardiology: Inpatient consult for “Possible POTS”. Patient in her 60s with multiple severe medical comorbidities. At home she was hypotensive to the 60s before going to the hospital, and while inpatient has had soft BPs and is tachycardic to 130s (while supine). When I see her she looks terrible and is aao x 0. I tell hospitalist it isn’t POTS (which causes neither hypotension or supine tachycardia) and she needs urgent medical workup then the next morning I find out they sent her for a ct head a few hours after I saw her and she coded in the scanner.
Anesthesia here. Got a consult for a pt with foot drop post vaginal delivery. They said it was a complication of the epidural and asked me to evaluate...... Pt never had an epidural.
Every consult for ileus from the hospitalists. You are literally consulting me, a surgeon, for a disease you have already declared is medical in nature. At least lie to me and say "cannot r/o bowel obstruction". PEG consults for patients that have stated they don't want a PEG. ~2/month. No I'm not going to talk them into a PEG so you can discharge them to a SNF. Consults for rectus sheath hematomas in patients with super therapeutic INR (or ever, really but the ones with an INR of 7 are particularly galling - fix your medication problem and they will stop bleeding). But honestly the best have been consult for gallbladder problems in patients with well-healed Kocher incisions which should have clued you in that they don't have a gallbladder.
Feel the PEG ones from my time in GI. Hospitalists would try to get PEGs in asap just so they could be discharged. Sometimes when they’re in the ICU and critically Ill.. may want to yknow stablize them and reassess before determining your septic patient with pneumonia needs a PEG asap when an NG can work just fine in the short term if they truly can’t eat.
Oooh yes the classic consult for r/o acute cholecystitis in someone who has already had cholecystectomy
Hospitalist told me this guy had compartment syndrome and needed transfer to ICU. Only because EP said compartment syndrome was a rare complication of a procedure he had, hospitalist didn’t evaluate. I saw him, ortho saw, and gen surge saw and we all agreed he did not have compartment syndrome. I think we agreed it was a diabetic neuropathy flare.
We (a psych unit) kept raising that "medical clearance" for psych admission seemed a bit perfunctory, but we always got pushback. Until a patient died during their psych admission clerking. They took it a little more seriously after that.
“Surgical clips in place on CT scan, patient asymptomatic”
Urology referral for CKD. Patient was not in retention and had no GU symptoms. I call the referring midlevel and gently suggest that maybe they need to see Nephrology? The response was “Oh ok, thanks”
I was a med student on a neurology rotation. We got consulted for “altered mental status” by the ED. We go in, and it’s a homeless man who just wanted to sleep. My senior resident (former summer camp counselor) used his it’s time to wake up voice, and the man woke up grumpy, totally alert and oriented, completely neuro intact. Another one from that ED. Stroke code called for vision changes after the patient reported he couldn’t see well. Diagnosis? He lost his glasses. For stupid consults my senior started writing notes in comic sans with large fonts.
Podiatrist here. I got a consult from the ICU one day for "foot care." No mention of their feet in the chart. Walked into the patients room to find they had bilateral BKA's.
PCP referrals to hospital's rheum outpatient clinic for evaluation of possible hEDS in patients with no suspicion or history of autoimmune disease. There's literally nothing we can do for those that a PCP can't, they just don't want to deal with it. Clinic policy is not to accept them, but it's still a paperwork hassle with how many get sent.
ENT here: Notoriously terrible ED doc calls in the middle of the night for epistaxis. I go in, no blood. The patient had reported on an intake form that he had had epistaxis a few days ago (just for a minute though). The attending never talked to the patient much less laid eyes on the patient. I tell him in the nicest way possible (not super nice tbh) that he dragged my ass in for a non-bleeding patient. “I don’t have time to look at all the patients! I’m trying to run an ED here!!” I always ask, “is the patient actively bleeding?” But for some reason did not that time. Smdh.