A Guide To Consults

A Guide to Consults Version 1.
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A Guide to Consults
Contents
A guide to making a medical consult ............................................................................................................................................................................................... 2
Anaesthetics ..................................................................................................................................................................................................................................... 3
Cardiology ........................................................................................................................................................................................................................................ 5
Cardiothoracic Surgery..................................................................................................................................................................................................................... 7
Endocrinology .................................................................................................................................................................................................................................. 9
Gastroenterology .......................................................................................................................................................................................................................... 11
General Surgery ............................................................................................................................................................................................................................. 17
Geriatrics ........................................................................................................................................................................................................................................ 19
Infectious Diseases......................................................................................................................................................................................................................... 20
Neurology....................................................................................................................................................................................................................................... 22
Orthopaedics.................................................................................................................................................................................................................................. 23
Psychiatry ....................................................................................................................................................................................................................................... 25
Renal .............................................................................................................................................................................................................................................. 27
Respiratory and Sleep Medicine .................................................................................................................................................................................................... 30
Rheumatology ................................................................................................................................................................................................................................ 32
Urology ........................................................................................................................................................................................................................................... 33
Brought to you by Liverpool Hospital Medical Officers Association

A Guide to Consults
A guide to making a medical consult
1. Introduce yourself. Name, position, team.

2. Clearly state what you are requesting from the registrar; your first remarks should reflect whether you are asking for phone advice or for a
consultation. “The reason I am calling you is..for phone advice / for a consult”
3. Identify the patient. State the patient’s name, age, location. Ask if the registrar would like the MRN now.
4. State what your working diagnosis is and specify whether you are asking for advice, a formal consult or take over care. “I think the patient might
have ____. My consultant / registrar would like you to see the patient with a view to take over care”
5. Mention the relevant comorbidities but know the remainder of the Past Medical History when asked
6. Make your requests brief: allow the registrar to ask additional questions if needed rather than flooding him or her with details initially.
7. State the urgency of the consult. “We understand you are busy but were hoping the patient could be seen this morning / today / this afternoon”
8. Thank the registrar, and ask them to contact you with any further questions or if they require you to order any further investigations.
9. ALWAYS ensure that you complete and place the consult sheet at the front of the patient’s file. Some consultants have a “No sheet, no consult”
policy.
GENERAL TIPS:
Before calling, ensure you are clear as to why you are asking for the consult. If you aren’t sure, clarify with your registrar first.
Have the relevant information in front of you: patient notes, medication chart, bloods, imaging.
Be honest. Don’t lie. If you don’t know, say you don’t know
Never make a consult without seeing the patient beforehand.
Be polite. Never confront the registrar. If you feel that your request isn’t getting anywhere, consider asking your registrar to speak to them.
Ideally, all consults should be made before 12.30pm. Obviously this isn’t always possible, especially when ward rounds go late, but you should try to
prioritise consults immediately after ward round. Unless it is urgent, no consults should be made past 3.30pm.
A special thanks to all of the registrars who have kindly provided information for this guide.

A Guide to Consults
Anaesthetics
GENERAL REQUIREMENTS FOR ALL CONSULTS IN THIS SPECIALTY:
HOW TO GO ABOUT GETTING AN ANAESTHETIC CONSULT 101:
Step 1: Call the anaesthetic department (83170) to see which anaesthetic reg you need to page to see the consult
- This is decided based on when the procedure is planned for (or if not known yet)
Step 2: If the patient is on the emergency list let the Duty Anaesthetist know about the patient (SD 2149)
- Often your registrar will already have done this so check with them
Don’t call me without knowing:
What procedure they are planning to do? (Ideally with the planned date)
Why does the patient need the procedure?
Why the patient is in hospital?
Background History esp cardiac, respiratory history
Medications esp anticoagulants (please check if the surgeon is happy to do the procedure on them or wants them stopped)
Recent abnormal bloods
Patient should be aware that they are having surgery!!

A Guide to Consults
Things you WILL get yelled at for Things that will get you Bonus points
Not knowing what the procedure is PLEASE chase old cardiology letters and TTE results
if the patient has seen a cardiologist
Not knowing the patients background PLEASE chase specialist letters
history or worse still making it up!!
Completely forgetting that the patient Patients >50yo or having large procedures need a
is on wafarin/heparin etc preop ECG
PAIN CONSULTS
Acute Pain Service – pager 25164 (0800-1800) or SD 2735 (1800-0800)
Chronic Pain Service – please fill in a consult sheet and fax it to 87205; chronic pain will then arrange for the patient to be reviewed. This may not occur on
the same day as referral.
Common reason for consult Relevant History Please Ensure
Acute Pain Consults Type of pain Make sure that the patient is on simple regular analgesia
e.g paracetamol
Suspected cause of pain
Current medications (including doses)
- Strongly suggest having the medchart when you call!
Chronic Pain Consults Type of Pain Any letters from previous pain consultatnts (outside
Liverpool)
Suspected cause of pain
Current medications (including doses)
Recent imaging is available
- Strongly suggest having the medchart when you call!
Previous treatment – surgery or previous pain reviews

A Guide to Consults
CARDIOLOGY
Cardiologist patient is known to
Letters from rooms
ECG
Medications
Not having the information in front of Apologising on behalf of registrar/consultant for

you (unless urgent consult) retarded consults upfront (we understand you are
the messenger but only if you pre-warn us!)
Non-urgent consults after 3.30 pm Asking for phone advice rather than formal consult
(consult etiquette!) if appropriate
st
Name, MRN, age and ward/bed 1 up

A Guide to Consults
SPECIFIC CONSULTS
Common reason for Relevant History Relevant Examination Investigations ordered

consult
Chest pain/IHD Prior coronary angio, stress test, MIBI results ECG, troponins
Arrhythmia CHADSVASc score (for AF/flutter only) K+, Mg2+, TSH levels, ECG
SOB/Heart Failure Prior ECHO results Weight change, RHF ECHO if none recent, CXR
(JVP/leg oedema) vs LHF
If infection possible ddx WCC/CRP
(APO) changes
If COPD possible ddx spirometry
Monitored bed Remember the role of telemetry is purely to monitor for life threatening
arrhythmias (mainly VT/VF)
The following is NOT an indication for a monitored bed:
Haemodynamically stable new AF
Haemodynamically stable SVT
Sinus tachycardia
Trop negative chest pain
Non-arrhythmic haemodynamic compromise (ie hypotension, shock etc)
refer HDU (except cardiogenic shock which can go to CCU)
ECHO Requests Please write what you are specifically looking for on the Powerchart
request – generic requests will go straight to the “ignore until team
discharges pt or rings up” pile
Only need to call the ECHO reg for urgent consults – all others will be
triaged based on Powerchart request info
“Urgent” = will alter immediate management today/tonight
If a patient is ready for discharge pending a non-urgent ECHO, consider
whether it can be booked as an outpt (ask your reg/consultant – most
can)
A Guide to Consults
CARDIOTHORACIC SURGERY
Initially state what exactly you are calling for (a 65 y/o male with tvd requiring cabg)... do not contact the registrar and give a million word essay over the
phone when they have not asked you for most of that information. Be concise and be ready. Know the medications, and know when exactly they have been
given.
Don’t call me without knowing: (History / Exam / Investigations
A proper history
Results of relevant investigations (it’s ok if they are missing, but know that they need to be done and don’t
start looking for them when you are on the phone)
A CXR, Trop, ECG, ECHO, and Angio is a must for most of the cardiology referrals
A CXR, a recent CT in cases of empyema or malignancy, resp. Function, ABG and full blood panel
All cases should have a recent INR and PLT count as all the operations we do have the potential for bleeding
and consequences are dire.

A Guide to Consults
SPECIFIC CONSULTS
Common reason for consult Relevant History Relevant Examination Investigations ordered
CABG Cardiac History/Renal/Respiratory/Neurologic/ Vascular examination, Varicosities, CXR, FBC, LFTS, EUC, Trop, CK MB,ECG,
Haematologic (HITTS, Coagulopathy, Cancers,...)/ GI Cardiac, Resp ECHO, Carotid Doppler in selective cases,
Bleeding/ Presence of active cancer/ Vascular (PVD, Resp Function, Coags, Hepatitis, Serology,
AAA, Previous Stripping of Veins...)/ Liver Functions/ BG and Hold
Substance Abuse (ETOH, Drugs,...)/ HIV, Hep C, Hep B
AVR As Above As Above Above + TTE
MVR As Above As Above Above + TTE + TOE
Resp Consults All above A recent CT in cases of empyema and lung
malignancies.
Additional:
Just when you call have everything ready, and please don’t go chasing the results when we are on the phone. If you don’t know something, just
say I don’t know. There are times that we are busy, literally saving lives and your non-urgent consult or request for a CABG in the next few days is
not going to be as important at that moment (it is important, but not as important as patient bleeding to death or crashing on the table). So,
despite all the effort we make to answer all the pages very fast, we might not be able to answer them, so if you don’t hear anything back and if it
can wait, please don’t page us back to back. If you don’t get through the pager, you can always find someone in the theatre. They can guide you
how to find the appropriate person. If you hear us cranky over the phone, it’s not because of you calling, it’s mainly the result of a million other
things that might be happening. So, don’t get upset.

A Guide to Consults
Endocrinology
Before you call , make yourself clear of what you are asking for( if you are not clear ask your senior team members)
Provide as much information as possible or available
DIABETES CONSULTS- Hyperglycemia or hypoglycaemia
BG for admission and current issues
Routine start: MRN, NAME , LOCATION,
CONSULT REASON; HYperglyemia/ hypoglycemia
Admitted for ………

1) type1 DM/ type2 DM or ?New onset
2) oral hypoglycemic agents +/- what doses of insulin
3) How long diabetic/ micro or macro vascular complications/ previous hyperglycaemic crisis/ Family Hx
4) Managed by GP/ endocrinologist/opthal review
5) Last HBA1C
6) Any ppt factors( eg steroid/ sepsis/ infections) or NG feeds
7) Current blood sugars( If BSL > 15-20 consider urine ketones+ finger prick ketones and if unwell blood gas)
8) Current renal function status( creatinine and eGFR)/( sodium/ serum osmolality- if in crisis)
9) Current HbA1c ( added on or pending) , Get recent blood results from GP if possible
10) Other BG history and explain current admission details
THYROID
1)Hypo or hyperthyroidism

A Guide to Consults
2) TSH ,FT3, Ft4 and Antibodies (thyroid peroxidise or thyroid microsomal, TSH receptor, Thyroglobulin
3) Febrile or recent illness / drugs/ recent exposure to contrast/ or any scans/ angiograms
4) Clinical features of hypo or hyper thyroid and duration of symptoms
5) If on thyroxine or carbimazole – dosage/ any recent change in dosage – if possible comment on ?Adherence/ expiry / storage
HYPO or HYPERCALCEMIA
1) Admission details
2) Symptomatic- paresthesias/ tingling / numbness/ palpitations/ dizziness/ abdominal pain/ spasms/ seizures
3) PTH , vitamin D and phosphate level/ renal function/TFT/ hydration status
4) ECG/ BMD/
5) relevant history of Parathyroid/ renal failure/ drugs/
6) History of osteoporosis/ malignancy/ any medications

A Guide to Consults
GASTROENTEROLOGY
History of prior gastroenterology review (either former consult (and by who) or outpatient review) +/- endoscopy
Relevant symptoms eg diarrhoea, constipation, change in bowel habit, weight loss, bleeding (and duration of symptoms)
Relevant signs eg fever, blood pressure and HR, location of abdominal pain, stigmata of chronic liver disease (if possible)
Note
Patient will not usually be jaundiced if bilirubin is < 80 ie patient with bilirubin of thirty will not be jaundiced or have scleral icterus;
PR bleeding general refers to lower gastrointestinal bleeding eg bright red blood compared with melaena which is black stool suggestive of upper
gastrointestinal bleeding (altered blood)
Relevant imaging - including current admission or preceding imaging
SPECIFIC CONSULTS

consult
? duration; ?previous investigations; ?iron deficiency; ?trajectory of Hb fall Iron studies

Anaemia PR exam if bleeding
? symptoms to suggest source eg change in stool colour/change in bowel habit suggested in history B12/folate
relevant medications eg antiplatelets/anticoagulation/NSAIDs/ PPI haemolysis screen (not always relevant)
coags

A Guide to Consults
first information usually desired is stability of patient eg BP and HR within BP & HR (including if U and Es esp urea
GI bleeding
normal range (or normal for that particular patient) and specific readings if postural changes)
FBC
asked, or if patient is unstable
Abdominal pain
other relevant initial information, especially if patient is unstable, is if patient is INR
known to have cirrhosis (previous documentation AND/OR stigmata CLD/high PR exam/stool chart
Erect CXR
bilirubin, low albumin and high INR), and particularly, portal hypertension (low
platelets a clue) – at risk for variceal bleeding which can require urgent
management
If patient is fasting
Diarrhoea Duration; how many times/day; nocturnal component; blood or mucous; Hydration state Baseline bloods, including TFTs
Associated hx: abdominal pain; fevers; weight loss; vomiting; recent antibiotics; Temperature; BP/HR
recent travel; sick contacts unwell; change in medications Stool MCS/ OCP (ova/cyst/parasite)/ C difficile
Abdominal exam
toxin
History if inflammatory bowel disease
Stool chart
History of constipation
Others may be requested:
Faecal elastase ?pancreatic insufficiency
Faecal anti trypsin ?protein losing enteropathy
AXR ?faecal loading ?bowel

distension/obstruction ?suggestion of colitis
?prior gastroscopy/colonoscopy
Deranged LFTs Prior LFTs/imaging Temperature Synthetic function – bilirubin/INR/albumin
Portal hypertension – thrombocytopaenia or

Trajectory of LFTs BP/HR
pancytopaenia

A Guide to Consults
Reason for admission Sats Transaminases – ALT/AST
Cholestasis – ALP/GGT
?recent hypotension Stigmata of CLD
RUQ pain/ other symptoms Hepatomegaly

Paracetamol level
Known chronic liver disease/cirrhosis Splenomegaly
Blood cultures if febrile
Other medical history ?eg haemolytic disorder Abdominal tenderness
Medications, including those recently ceased as well as PRNs Ascites Liver screen (not expected to know but may be
asked for):
Heart failure
Viral
Alcohol history BMI
Hepatitis BsAb (prior vaccination if remaining profile
Risk factors for viral hepatitis – ethnicity; hx of IDU Alertness/orientation negative)
Hepatitis BcAb
Asterixis
Hepatitis BsAg
If history of cirrhosis ?ascites ?prior spontaneous bacterial peritonitits (SBP)
?encephalopathy Hep BeAg/eAb/viral load if chronic infection
Hepatitis C core Ab
EBV/CMV IgM/IgG
HIV if risk factors
Autoimmune
AMA (primary biliary cirrhosis)
ANA/Smooth muscle antibody (SMA)/ anti liver

kidney microsomal antibody (autoimmune hepatitis)
Immunoglobulins (IgG AIH; IgM PBC)
ANCA

A Guide to Consults
Others
Iron studies
Caeruloplasmin
Alpha anti trypsin
Celiac serology
Fasting lipids/glucose
If cirrhosis –alpha fetoprotein
Abdo US+/- CT abdomen
Ascitic tap:
Biochemistry (albumin, protein, LDH)
MCS
Cytology
Dysphagia Duration; ?solids ?liquids ?both Neck examination Baseline bloods
CXR
Other symptoms – painful/ location of difficulty/ weight loss
Prior investigations, esp endoscopy or barium swallow

May be asked for:
?speech pathology assessment
Barium swallow

A Guide to Consults
CT
Known/suspected When diagnosed Fevers; BP/HR Baseline bloods, including CRP

Inflammatory Bowel Faeces MCS/C dif toxin
How diagnosed ?endoscopy ?imaging Abdominal tenderness
Disease
AXR
UC or CD PR exam (esp if perianal
exam)
Part of bowel affected – small bowel; perianal disease; colonic; upper GI
(Crohns)/ colonic (UC) Stool chart
May require:
If known to a specialist
CT/MRI abdo
Medications (oral;topical; injections)
Endoscopic assessment
5ASAs
Prednisone
Immunomodulators (Azathioprine/6MP/Methotrexate)
Biologics
(Infliximab (Remicade); Adaliminab (Humira)
History of surgery – where/when/by whom
Current presentation ?diarrhoea (how much; ?nocturnal; ?blood); ?abdominal

pain; ?urgency ?typical for usual flares
PEG request Reason for PEG Baseline bloods, including coags
If it has been discussed with patient (if competent) and family

A Guide to Consults
Antiplatelets or anticoagulation May be asked to arrange an anaesthetics

review
Prior abdominal surgery
Past medical history
Tracking down prior clinic letters/imaging or

Not following through with consult
requests/ suggestions (providing rest of endoscopy results
team is in agreeance)
Anything else you would like included:
Generally if consults have been seen by a registrar in the current admission already, contact the initial registrar
Try not to delay making contact for potentially urgent consults eg GI bleeding; cholangitis; IBD flare
If patient is non English speaking, please notify and arranging an interpeter/family member to be present can be discussed
If patient is not likely to be on ward eg radiotherapy, imaging etc, let registrar know

A Guide to Consults
General Surgery
Introduce yourself and why you are calling

Patient name/ age/ location / mrn
pertinent positives and pertinent negatives
My team would like : colonoscopy / review for ?surgery / (what you actually want)
State the urgency of the consult early on
Have information about bloods, imaging, etc (be in front of your computer)
Be polite and don’t confront the registrar
Never make a consult without first seeing the patient

The Patient’s comorbidities
Previous colonoscopy / endoscopy / surgeries + the results of these (if applicable)
Scan and blood results

A Guide to Consults
SPECIFIC CONSULTS
General surgery covers a lot of conditions but hopefully the list below will give you some tips.
PR bleeding Onset, colour, amount etc Vitals, PR examination Hb, urea, stool chart (colour etc)
SBO Insert NGT Erect + supine XR
IDC + strict fluid balance CT
Appendicitis Migration, duration, N + V, fever Signs of peritonism, guarding WCC / left shift, +/- US if available, Urine
and if female BHCG
Pancreatitis Alcoholic verse gallstones, age Glucose, LDG, AST, ECC, Ca, Hct, O2, BUN
CT if available
US results for gallstones if available
Diverticulitis Generalised verse localised pain, WCC, CRP, CT
rebound, rigidity

A Guide to Consults
Geriatrics
GERIATRICS: EG., REVIEW FOR ACAT ASSESSMENT/PLACEMENT
Don’t call me without knowing
Patient’s pre-morbid & current functional status, current admission reason, Investigations, Management/Complications. NoK/Family’s understanding of need for
placement
Reason for a discharge destination other than home
Anticipated/ongoing needs; ie dialysis, chemo, IV antibiotics etc.,
unstable patient not yet ready for Good documentation of

ACAT assessment history/exam/management plan warranting
placement
No formal consensus on discharge Advanced Care Directives if any

destination
Patchy history Family conference details / documentation
Medication review and reconcilitation

A Guide to Consults
Infectious Diseases
Why you are calling (e.g. advice on antibiotic choice, antibiotic duration, help with diagnosis, etc.)
ALL positive (and relevant negative) microbiology results for this clinical episode
ALL antimicrobials the patient is receiving and has previously received during this clinical episode (incl. outpatient if possible)
ALL antibiotic allergies/ intolerances, including nature of the reaction
Forgot patient’s name/ MRN Look up your question in Therapeutic guidelines:

antibiotic before calling
Only mention critical result (e.g. blood culture) Make consults before midday
at end of discussion
Having to call back because it turns out you Specify upfront if you want phone advice (often
didn’t mention the patient is allergic to the sufficient for simple antibiotic/ investigation
antibiotic recommended during previous call advice) or a consult (i.e. you need the patient to
(Still call though, and cop it!) be seen by the ID team)

A Guide to Consults
SPECIFIC CONSULTS

consult
Cellulitis Injury, vascular disease, diabetes, ulcers Boils/ wounds? Wound swabs, blood culture if febrile
Diabetic foot infections Ulcers, previous Rx/ amputations Ulcer – is bone visible? Is there Wound swap +/- blood culture, x-ray
cellulitis?
Bone and joint infections Onset, hardware present, timing of surgery Cellulitis, sinus x-ray, joint aspirate culture
Urinary tract infection Catheters/ stents, uro- surgery, previous Urine culture +/- blood culture
episodes
Fever, cause unknown Onset, measured temp, travel, Full Blood, urine, other relevant culture
comorbidites/meds
Additional:
During the day you will be called by the microbiology registrar about critical results from time to time. Be aware that our
microbiology registrars are ID trained and calling the ID registrar for confirmation of advice is not generally necessary unless a formal
consult is required. (Note that after-hours the lab scientists will phone out critical results. They are NOT clinically trained and will not
give treatment advice)
The ID and microbiology registrars are generally good natured and happy to be called about infectious diseases, antibiotic and results
advice. However we frequently get swamped with calls, so please be patient if you can’t get through immediately and try again later
(and please call during working hours if at all possible).

A Guide to Consults
Neurology
History: patient’s age, sex, reason for admission and neurological symptoms
Brief exam findings eg: right hemiplegia…visual loss in one or both the eyes.
Investigations eg: ct brain, mri brain if done
JMOs to clearly state the REASON FOR CONSULT AND THE EXACT QUESTION POSED TO THE NEURO TEAM for example: assessment for stroke, evaluation of
Parkinson’s disease, workup for a possible neuropathy/myopathy , evaluation of a patient with frequent falls etc…..
SPECIFIC CONSULTS
stroke Weakness, numbness Motor and sensory Ct or mri brain

Parkinson’s disease Duration, meds , falls etc rigidity
Incomplete history, exam and Good history and exam with clear reason for
definitely unclear reason for consult consult
and trust me it happens often

A Guide to Consults
Orthopaedics
Patient name, age, location, MRN, History and the reason for the orthopaedic consult. Eg Fracture / pain / infection / compartment syndrome.
What orthopaedic question your consultant wants answered? Past history of trauma or orthopaedic operations eg knee replacement. Functional
limitations eg. Unable to move upper limb due to pain
Investigations – specifically CRP / ESR if query is infection / osteomyelitis / septic arthritis. Xrays including joint above and below for most
orthopaedic consults
Examination – ideally range of motion of affected joint, able to weight bear or not, prior walking status – has it changed?
Any other relevant history / medical problems / anticoagulants / previous similar problems
SPECIFIC CONSULTS

consult
Fracture How / when / where / which bone / joints above and below Neurovascular status. Open or closed? XR
Compartment Injury / time of injury / analgesic requirements / pain on XR
syndrome passive stretch
Septic arthritis History, fevers, recent source Range of motion / weight bearing XR, CRP, WCC, ESR
Osteomyelitis As above plus any skin defects or ulcers As above XR, CRP, WCC, ESR bone scan alone not
specific, think of WCC scan or gallium but
discuss with us or your consultant first

A Guide to Consults
You shouldn’t be yelled at for any question – it is a Being able to describe a fracture with regards to displacement /
consultant to consultant referral… you are only the comminution / intraarticular
messenger
Thinking of what an anaesthetist may ask if the patient needs surgery
Learn how to put on a backslab (Physio’s can teach you this in ED)
ADDITIONAL:
The orthopaedic department feel that most consults should be seen within 24 hours… feel free to keep contacting us if this has not happened.
The orthopaedic “on call” pager is active from 0730 – 1640 #49762. After hours we are offsite so ring mobile via switch
If no answer try theatres – 2150 is the number fo theatre NUM in charge, Theatre 8 87808. Theatre 6 87806
All registrars are happy to be contacted on their mobile phones. If you leave a message state the reason / patient name and location. We will
often get out of theatre long after you have gone home but feel free to leave contact details as well
If all of the above fails and your consult is urgent call the orthopaedic consultant on call who will definitely find you a registrar
As an intern, you will learn that there are different varieties of orthopaedic registrars – some will ask lots of questions / be rude / not see patient
until you have ordered extra tests. My personal opinion is that if your boss has asked us to see a patient then we should do that and discuss with
the orthopaedic surgeon on call. If you are meeting a “wall” then you should involve your registrar +/- boss

A Guide to Consults
Psychiatry
- Previous Psych History, especially self harm/harm to others
- Knowing common symptoms of Mental Ilnesses and having asked them- you screen, we establish a diagnosis
- If the patient speaks fluent English.

- Is the patient able to speak? (eg Intubated)
- What are the acute risks? Self neglect, reputation, aggression, active suicidality ,homicidality etc..
SPECIFIC CONSULTS

consult
Depression Duration, biological and psychological symptoms MSE
of depression, risk issues-thoughts of self harm
or suicide
Adjustment disorder Patient’s reaction to the medical condition. MSE, Collateral information from
Temporal relationship with the medical problem. family and GP
Depressive and anxiety symptoms
Delirium Orientation questions, sudden change in An investigation being normal doesn’t
behaviour, delirium is a medical emergency- look rule out delirium.

A Guide to Consults
for medical causes. Assess for psychotic

symptoms and risk issues.
Suicidality Thought/Plans/Intent? Previous History MSE
Saying patient is teary, so she must be Speaking to the family

depressed Speaking to the GP to get the history
Please speak to the patient and assess for the Looking at the past history – old notes
condition
Patient who has a chronic psychotic illness
which is managed by the community team don’t
need inpatient review just because they have a
diagnosis. What is the acute issue now?
Asking us for a consult without having asked the
patient first if he or she is happy to see us

A Guide to Consults
RENAL
Baseline renal function
Patient’s volume status – dry vs euvolaemic vs fluid overloaded
Relevant medications
Urine dipstick result if one done in ED (most patients have one) or formal MCS/PCR result if available
Telling the renal registrar the patient has acute kidney injury but not knowing Giving a clear and succinct history and clearly identified reason for consult with
the baseline renal function because there are no previous bloods on appropriate investigation results.
Powerchart and you haven’t bothered calling any of the private laboratory
companies to find out
Patient’s renal function at baseline and asking for renal consult without a Making an attempt to formulate a hypothesis or diagnosis for your patient’s
specific clinical question problem ie. “I think my patient has ….”
Requesting consult for management of hyperkalaemia without having
initiated any treatment
Asking for a consult on Friday afternoon because ‘the weekend is coming up’
when the patient has been in hospital all week and the problem has been
there for the last several days

A Guide to Consults
SPECIFIC CONSULTS
Acute kidney injury Drugs, nausea/vomiting/diarrhoea/fever, significant BP, volume status, urine output (? Urine MCS/PCR/ACR (most patients
heart disease/cirrhosis, diabetes Oliguria/anuria/polyuria) have urine dipstick in ED – very helpful)
Imaging renal tract – size of kidneys,
?stones, ?obstruction, ?prostatic
hypertrophy
“Can patient have CT with IV Baseline eGFR + current renal function Volume status
contrast or angiogram?” Indication for contrast – if not at baseline, can scan
or wait until AKI improves or is there an alternative
imaging modality that can provide same
Optimisation of renal
function prior to … information?
Current medications
Does patient need dialysis? Baseline renal function ?AKI or known end-stage Volume status, urine output Electrolytes esp. Na, K+, HCO3-, Urea,
renal failure cCa
Current active issues + important background
medical history
Hyponatraemia Baseline Na+ and renal function, active medical BP, volume status, urine output UEC, serum osmolality, urine Na+ and
issues, ? on IV fluids, current medications ?diuretics osmolality, TFT, ACTH/cortisol
Does patient need biopsy? ? history of vasculitis or rhematologic disease, Renal tract imaging – size of kidneys,
current and baseline renal function, what diagnosis renal function, albumin, urine
you are looking for/trying to exclude ?haematuria, degree of proteinuria, any
casts?
Hyperkalaemia Baseline renal function + potassium Does patient have IV access? ECG – changes of hyperkalaemia/
management Current medications arrhythmia??
What have you done for the hyperkalaemia besides
calling the renal registrar??

A Guide to Consults
ADDITIONAL:
Numbers of major pathology companies to call for results (90% patients have blood results at one of the top 2 numbers) – available 24/24:
Douglas Hanly Moir 9855 5100
Laverty 133 936
Med Lab 1300 633 522
Healthscope 1300 134 111
Sydpath 8382 9100
DMC 9370 8400
If someone is hyperkalaemic (potassium >6) requiring treatment, calcium gluconate or insulin or bicarbonate or salbutamol do NOT remove the potassium from the
body but shift the potassium into different compartments. To definitively remove potassium, you need to EXCRETE potassium (in gastrointestinal tract by use of
resonium OR in urinary tract by use of frusemide OR by dialysis).
Any haemodialysis or peritoneal dialysis or renal transplant patients that are not admitted under the renal team – please let us know! We would rather see these
patients early than when something terrible happens to them and have to fix any problems. We may also need to arrange dialysis and changes in medications to
help optimise your patients (prior to any procedures/surgery etc) as renal patients are really quite difficult medical patients.
Renal registrars don’t bite but we DO have a large volume of calls and consults – we appreciate your help in having some idea what is happening with your patients
when you call us!

A Guide to Consults
Respiratory and Sleep Medicine
History
Auscultation findings, vital signs – RR, temp, spo2
Cxr
Spirometry requested (powerchart physio to do)
SPECIFIC CONSULTS
Pre-op optimisation History of chronic lung disease, smoking history, Auscultation, sputum volume, infective ABG, CXR spirometry, sputum m/c/s
occupational dust exposre etc symptoms, VITAL SIGNS
Management of chronic lung “, exercise tolerance “ “
disease
Hospital acquired pneumonia Admission history, aspiration? MROs? “ CXR, sputum culture
PE Risk factors, symptoms “ – vital signs, BP Relevant scan, ECG
OSA (?) Snoring, witnessed apnoeas, daytime somnolence Obese? History of CVD, NMD, CVA? Spirometry, ABG
Spirometry is contraindicated in Any past correspondence from resp physician

pneumothorax!

A Guide to Consults
Additional:
Call for all routine consults prior to midday when possible. If consult is urgent, let the registrar know. Always call with a question to be answered
by the consulting team, KNOW your patient. Consult sheet is very important – some consultants have a ‘no consult sheet, no consult’ policy which
is a big time waster so don;t forget the sheet.

A Guide to Consults
Rheumatology
All past medical diagnoses
Chronic rheum Disease History (if applicable): usual rheumatologist/specialist/previous significant management/complications [prev letters
from treating rheumatologist would suffice - a phone call away!]
Medications, including yearly infusions/monthly injections commonly not listed unless asked eg. Aclasta/Humira/Enbrel/Infliximab
Reason and course of current admission
Current Consult question with preliminary relevant signs/history/investigations
Eg. Is this lupus - no arthritis/rash/myalgia/renal disease; ANA/ENA/dsDNA/C3/4; ANCA for vasculitis; RF and CCP for new inflammatory
arthritis; Xrays hands/wrists/feet and affected parts
Joint aspirate results if applicable (cell count, crystals, culture)
Don't forget:
Urine protein: creat ratio and casts for any autoimmune/vasculitis consults
ESR/CRP please if PMR/GCA/vasculitis/RA suspicion

A Guide to Consults
Urology
Basic history and examination is required with any Urology consults. Introduce yourself and where you’re calling from – Ward / ED / Team.
You were taught in medical school to start from history and examination but will soon realise that for surgical consults we want to know succinctly
what the problem is – For example : 55 year old male with left flank pain and macroscopic haematuria of 3 days with a CT KUB showing a 6mm
proximal left ureteric stone. No fevers chills or rigors. HD stable. Abdomen soft left flank pain. Bloods show – WCC, HB, CRP, EUCs. Any other imaging
done shows – CT IVP etc. In terms of management – IVT / NBM / Analgesia / Cultures if febrile etc. Can I get advise on what else you’d like for this
patient and if he needs an admission? Management can happen prior to personally assessing the patient.
Work up your patients well and you won’t have any issues
As an intern your registration is provisional therefore if you’re calling from ED, your ED registrar or staff specialist would have to see the patient to
decide whether he/she’d agree with your history examination and management - A common differential of renal colic could potentially end up as a
ruptured abdominal aortic aneurysm. A septic patient with an obstructed stone has the potential to rapidly deteriorate and may need more than just
IV fluid resuscitation – In other words, you’ll learn on the job through apprenticeship what needs to be done. If you don’t ask that’s when troubles
arise.
Find out more about the background of a patient – If he’s known to Urologists and the previous procedures he’s had done. If it makes sense to you
it’ll make sense to us as well – or with whatever information you pull, we’ll try to make some sense of it.
Surgical consults – Needs without hesistation FBC EUC CMP CRP LFT coags MSU UA, blood cultures if fevers >37.5 CXR. VBG if septic and looking uwell
checking for a baseline lactate. Urgent imaging with CT.

A Guide to Consults
SPECIFIC CONSULTS
Renal colic Imaging imaging imaging. – CT KUB diagnosis until Haemodynamics and temperature UA, MSU MCS, FBC, EUC, CRP
proven otherwise
CTKUB
If discharging small stones < or = 4mm will need
analgesia regular flomaxtra 400mcg daily for 4 weeks
script and a follow up outpatient CT KUB to document
clearance of stone with GP
Renal colic with fevers / Urgent CTKUB! If you have a strong suspicision of Bloods and cultures with immediate
Septic stone renal colic and a bedside USS showing hydronephrosis CTKUB NBM
with positive UA for leukocytes / nitrites – Please
Post void residual bladder scan – If in
expedite a CTKUB and keep the patient fasted.
retention – for IDC
Immediate call to Urology
Testicular torsion Time and date of onset of pain in testicle. Acute or Scrotal examination + abdominal UA MSU PCR chlaymydia and gonorrhoea
chronic - Increasing pain instantly or gradually over examination
Routine bloods
many hours / days. Sexual history. High risk age group
12-25. Immediate call to Urology USS Scrotum – Immediately!
The Urology department in Liverpool does not cover
kids below 12 years of age strictly – they would have
to be referred immediately to Westmead childrens
Acute urinary retention BPH ?on alpha blockers – flomaxtra / prazocin / Abdominal examination MSU MCS bloods
duodart. Previous TURP or operations. Urethral
IDC
strictures?
Bladder scan – post void residual and
voided volumes.
Renal tract USS including prostate vol
estimate and pre and post void residuals
– Needs full bladder
Urosepsis History of recurrent UTIs / BPH Bloods + relevant cultures
Onset of fevers / pain Imaging if flank pain to exclude
A Guide to Consults
obstructing stone
IDC
Fluid resuscitation
Haematuria Onset on haematuria. Fevers. Clot retention or Urgent bladder scan - Post void
Abdominal examination
passing clots. Pain. residual and voided volume.
Recent operations / TURP / UTI / Bladder CA Full bloods
Anticoagulation - Aspirin / plavix / warfarin / new Imaging - usually CTKUB / USS Renal
anticoagulation agents tract with prostate volume and pre and
Age post void residuals
smoking history and risk factors for CA If passing macroscopic haematuria
with clots - will need 3 way IDC with
irrigation +/- PRN manual irrigation to
get rid of larger clots
Urine cytology x3 + MSU
If urine showing leukocytes / nitrites -
treat UTI with ABx cover especially if
fevers
No imaging A sensible approach to examination history and

management
No bloods A professional demeanor
No senior doctor review prior towards calling
Poorly resuscitated patient
Feeding the patient if surgery is likely to happen for kidney
stones or torsion
Post radical prostate - Urinary retention - Catheter insertions

must be performed by Urology registrars.

A Guide To Consults

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A Guide to Consults Version 1.

Brought to you by your LMOA

Brought to you by Liverpool Hospital Medical Officers Association

A guide to making a medical consult

1. Introduce yourself. Name, position, team.

Brought to you by Liverpool Hospital Medical Officers Association

Don’t call me without knowing:

Why does the patient need the procedure?

Why the patient is in hospital?

Background History esp cardiac, respiratory history

Recent abnormal bloods

Patient should be aware that they are having surgery!!

Brought to you by Liverpool Hospital Medical Officers Association

Common reason for consult Relevant History Please Ensure

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Don’t call me without knowing:

Cardiologist patient is known to

Letters from rooms

Not having the information in front of Apologising on behalf of registrar/consultant for

Brought to you by Liverpool Hospital Medical Officers Association

Common reason for Relevant History Relevant Examination Investigations ordered

Don’t call me without knowing: (History / Exam / Investigations

Brought to you by Liverpool Hospital Medical Officers Association

Brought to you by Liverpool Hospital Medical Officers Association

Provide as much information as possible or available

DIABETES CONSULTS- Hyperglycemia or hypoglycaemia

BG for admission and current issues

Routine start: MRN, NAME , LOCATION,

CONSULT REASON; HYperglyemia/ hypoglycemia

Admitted for ………

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4) Clinical features of hypo or hyper thyroid and duration of symptoms

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Relevant imaging - including current admission or preceding imaging

Common reason for Relevant History Relevant Examination Investigations ordered

? duration; ?previous investigations; ?iron deficiency; ?trajectory of Hb fall Iron studies

relevant medications eg antiplatelets/anticoagulation/NSAIDs/ PPI haemolysis screen (not always relevant)

Brought to you by Liverpool Hospital Medical Officers Association

Faecal elastase ?pancreatic insufficiency

Faecal anti trypsin ?protein losing enteropathy

AXR ?faecal loading ?bowel

Deranged LFTs Prior LFTs/imaging Temperature Synthetic function – bilirubin/INR/albumin

Portal hypertension – thrombocytopaenia or

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Reason for admission Sats Transaminases – ALT/AST

RUQ pain/ other symptoms Hepatomegaly

HIV if risk factors

AMA (primary biliary cirrhosis)

ANA/Smooth muscle antibody (SMA)/ anti liver

Immunoglobulins (IgG AIH; IgM PBC)

Brought to you by Liverpool Hospital Medical Officers Association

Alpha anti trypsin

If cirrhosis –alpha fetoprotein

Abdo US+/- CT abdomen

Biochemistry (albumin, protein, LDH)

Dysphagia Duration; ?solids ?liquids ?both Neck examination Baseline bloods

Prior investigations, esp endoscopy or barium swallow

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Known/suspected When diagnosed Fevers; BP/HR Baseline bloods, including CRP

(Infliximab (Remicade); Adaliminab (Humira)

History of surgery – where/when/by whom

Current presentation ?diarrhoea (how much; ?nocturnal; ?blood); ?abdominal

PEG request Reason for PEG Baseline bloods, including coags