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Introduction

Effective clinical handover can reduce communication errors between health professionals and improve patient safety and care.

Clinical communication problems are a major contributing factor in 70% of hospital sentinel events leading to an increased risk for adverse events. Adverse events are seen to increase particularly during transition of care, when a patient is transferred between units, physicians and teams. Poor or absent clinical handover, or failure to transfer responsibility and accountability, can have extremely serious consequences for patients. It can result in a delay in diagnosis or treatment, tests being missed or duplicated and can lead to the wrong treatment or wrong medication being administered to the patient. Clinical communication is an essential element to ensure safe and high quality health care delivery.

All clinicians have a professional responsibility to ensure that information regarding patient care/status is communicated and received in a manner that is effective, structured and ensures that essential information is transferred/relayed. Communicating clinical information from one clinician to another is about ensuring effective continuity of care for patients. It must occur at ‘transition care points’. These arise in many situations including but not limited to shift change, patient transfers, and escalation of deteriorating patients, intra-and inter-hospital transfers, multidisciplinary and interdisciplinary handover and at discharge from inpatient or outpatient care and community-based services.

When escalating clinical concerns to a consultant or making a referral, the Junior Medical Officer should present information according to the ISBAR communication framework. All escalation communication is undertaken using an ISBAR format to ensure the succinct handover of clinically relevant information. It remains incumbent upon the consultant to ask pertinent questions if they are unsatisfied with the completeness of the clinical handover, and to consider physically reviewing the patient when indicated.

** All calls/refer MET to a consults should be contemporaneously documented in the patient medical record as verbal handover alone results in poor information retention.

 

Cardiology

1. Mechanism for Requestion a Consult
Determine from switch who the cardiology consultant of the day is Page the registrar assigned to the on call cardiologist

 

2. Common questions/reasons for consults to this Specialty
  • Troponin rise
  • AF and other cardiac arrhythmias/ECG abnormalities
  • Syncope
  • Pre-op assessment
  • Is this cardiac failure or optimisation of cardiac failure

 

3. General clinical information/questions relevant to consults to this Specialty
Essential
  • Proper characterisation of chest pain
  • ECG and CXR findings
  • Past ECG if available

 

4. Common question-specific information required
Are they known to a cardiologist/been admitted under a cardiologist before at this hospital? (If so, the registrar for that consultant does the consult)

 

5. Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc)
Essential
    Results of previous cardiac investigations ie. Angiogram and TTE and details of previous cardiac procedures/surgery.
  • Patient’s Cardiologist’s clinic notes

 

6. Family/social history relevant to consults to this Specialty
Level of function and mobility

 

7. Medications relevant to consultations to this Specialty
  • Cardiac related meds
  • Anticoagulants

 

8. Investigations relevant to consultations to this Specialty
  • ECG
  • CXR
  • FBC, EUC, CMP, LFT, Coagulation studies
  • TTE
  • Angiograms

 

9. Investigations relevant to consultations to this Specialty (and why)
TTE: (LV regional wall motion abnormalities/right ventricular dysfunction in trop rise and SOB, LV and valvular function in ?heart failure, structural abnormalities and ventricular function in arrhythmias.

 

10. Extra tips for acquiring consults
Try to assemble the results of previous investigations, old notes (and old ECGs) and specialist clinic letters when trying obtain the consult. Hopefully this will be available to review by the time the patient is seen.

 

Dec 2016

 

Drug Health

Common questions/reasons for consults to this Specialty
  • Intoxication
  • Drug/Alcohol withdrawal syndrome
  • D&A related pathology, e.g.: alcoholic liver disease, bacterial endocarditis from IDU (Injecting drug use)
  • Patient presents while on OST (Opioid Substitution Treatment) with any acute illness
  • Recurrent presentation with acute/chronic pain and drug-seeking suspected
  • Altered mental state with a context of recent/chronic D&A use.
  • Unusual or unexplained bacterial pathology

 

General clinical information/questions relevant to consults to this Specialty
Essential
  • History of recent intake of Drugs and/or Alcohol: how much and how often for each substance in question. Hint: to quantify illicit drug use, ask about the dollar value used at street prices
  • Reason for presentation, history of presenting illness
  • General medical, surgical and psychiatric history
  • Basic examination with attention to clinical signs typical of Drug or Alcohol use.
  • Brief but careful MSE (mental state examination).
  • A clearly worded question posed to the D&A CL team to assist with diagnosis and/or treatment

 

Helpful
  • Long term history of Drug and Alcohol use
  • Social history
  • Results of recent Investigations/admissions performed outside WSLHD

 

Common question-specific information required
Intoxication:
What are the clinical features that suggest this?

Drug/Alcohol withdrawal syndrome:
What are relevant signs and symptoms?

D&A related pathology:
What is the nature of the problem? Do you think Drug/Alcohol use is part of the aetiology?

Patient presents while on OST:
Which drug is the patient on (buprenorphine or methadone), what is the dose, when & where was the last dose given and who is the prescriber? Does the patients have active and/or old track marks in the cubital fossae, femoral and jugular regions?

Acute/chronic pain:
Is there demonstrable pathology to explain the pain? What is the pattern of drug requests? Why do you suspect drug-seeking?

Altered mental state:
What is the current mental state consistent with? Delirium, Dementia, Psychosis, Depression or other? How does recent D&A use relate to the mental state temporally?

Bacterial pathology:
Is there a history of IDU? Any fresh track marks? If the patient is on OST, is diversion suspected?

 

Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc.)
  • Previous contact with D&A services.
  • Admissions to detox units and rehabilitation facilities.
  • Other medical treatment for D&A disorders in particular and other specialist reports and discharge summaries for other related and co-morbid conditions.

 

Family/social history relevant to consults to this Specialty
Essential
  • Where does the patient live and who with?
  • Does the patients have children in their care and if so, who is looking after them now?

 

Helpful
  • What is the patient’s occupation/source of income?
  • Is the patient of CALD/Aboriginal background?
  • Does the patients have a forensic history? If so, when was the first and last stay in custody and total time spent in custody. Were the alleged offences due to Drug or Alcohol use?

 

Medications relevant to consultations to this Specialty
  • All medications, especially all psychiatric and psychoactive drugs
  • S4 and S8 drugs
  • Medications specifically used to treat D&A disorders such as OST (as above) and anti-craving agents for alcohol dependency.
  • OTC preparations that can be misused, e.g.: Nurofen Plus, Unisom capsules

 

Investigations relevant to consults to this Specialty
  • Urine drug screens (relevant to illicit and prescription drug use)
  • HBV, HCV, HIV serology and blood cultures when indicated (with a history of IDU)
  • General blood tests with attention to alcohol biomarkers: LFT’s, MCV, Plt count, Mg++, K+, albumin, INR (when chronic alcohol use suspected)
  • Blood or Breath alcohol level (always to be done when possible in the setting of intoxication). It is inadequate to avoid doing a BAL if other blood test are able to be performed.
  • ECG (to screen for prolonged QTc in patients on high dose methadone or in such patients with suspected VT/Torsades)

 

Extra tips for acquiring consults
  • Take a history and perform an examination before calling for a consult.
  • Think: if overdose suspected, does Toxicology need to be contacted? If MSE abnormal, does the Mental Health team need to be involved?

 

Common problems in calls for consults
  • Not knowing who to call and when
  • Calling without a basic assessment performed beforehand
  • Not calling when it could be helpful
    • Not calling to avoid disturbing the Dr on call (service is on call 24/7) when prompt advice might help
  • Calling for a consult when the patient has been in hospital for days and discharge is imminent
  • No clear rationale for the consult

 

Intensive Care Unit

Ward staff requiring urgent review of deteriorating patients, must initiate an MET call via the Hospital switchboard. The switchboard will then issue an ‘MET call’ via the emergency paging system. This will send a message for the MET team to attend urgently. The MET team is comprised of the Medical Registrar (MET Team Leader), Anaesthetic Registrar and the ICU Registrar.

During the day, the ICU Registrar who is carrying the MET pager will attend the MET/cardiac arrest/trauma call. The ICU Senior Registrar need only attend as a back-up if required by the ICU Registrar.

At night, one of the Night Registrars, will carry the MET pager and attend the MET / cardiac arrest.

All Emergency Department, Operating Theatre and Out-of-Hospital initiated referral calls to ICU should be passed to the senior registrar on 7571, 24 hours a day, 7 days a week.

In business hours, this will be answered by the on-site ICU Senior Registrar (SR) After-hours the SR will review or call in person. If the SR is offsite he will ask the registrar to review and liaise regarding the potential admission to the ICU.

An exception to the rule of urgent review is as follows. For ward patients admitted under a specialist, an ICU Consultation can be initiated by someone of Registrar level or above by contacting the ICU Senior Registrar (pager via switch) 24/7 on 7571.This referral must never be delegated to a more junior member of the referring medical team or ICU team. The Registrar must have first discussed the need for referral to ICU with the primary Consultant (or the designated on-call Consultant for that particular specialty or sub-specialty).

If the patient is unwell and breaches the calling criteria after the referral then and MET call should be initiated. Referral is not a substitute for MET. And Urgent reviews would warrant a clinical review or MET as deemed appropriate by the team.

Any patient in whom 2 or more MET calls have been made within 24 hours or the teams are concerned must be discussed with an ICU Consultant.

IT IS NOT ADVISABLE FOR TEAMS TO RING THE ICU DIRECTLY TO SPEAK TO an ICU Registrar as it affects the clinical work and does not identify the right person. This can be used to escalate if the pager has not been answered for whatever reasons.

 

Infectious Diseases

Common questions/reasons for consults to this Specialty
  • Empiric antibiotic therapy
  • Targeted antibiotic therapy
  • Duration of antibiotic therapy
  • Fever ?source
  • Post-Acute Community Care (PACC) intravenous antibiotics


General clinical information/questions relevant to consults to this Specialty
  • Fever – onset, course
  • Septic screen – UA, urine MC&S, CXR, Bcx3
  • Imaging results
  • Previous and current microbiology results – source, bugs & sensitivities
  • Antibiotic therapy – IV & PO drug, dose, dates, reason for changing


Common question-specific information required
  • What surgery has occurred, what were the intra-operative findings?
  • What surgery is planned?
  • What immunosuppression have they received?
  • How long have they been neutropaenic, how long are they expected to be neutropaenic?

Background Medical History relevant to consults to this Specialty
(E.g. previous contact with Specialty, letters, reports, o/s travel, etc.)

Essential
  • Allergies – what reaction & when?
  • Asplenia Which infectious Diseases specialists have they seen & when – obtain letters
  • Microbiology reports – chase sensitivities


Context-specific
  • Sick contacts
  • Overseas travel – locations, duration, accommodation, activities, health-care contact
  • Bush contact
  • Animal contact


Family/social history relevant to consults to this Specialty
Essential
  • Occupation
  • Smoking


Helpful
  • Vaccinations
  • IVDU
  • Sexual history


Medications relevant to consultations to this Specialty
  • AntimicrobiMET
  • Immunosuppressant’s
  • Insulin
  • Warfarin & other drugs with interactions
  • over-the-counter medications


Investigations relevant to consultations to this Specialty
  • FBC, CRP
  • Renal function, liver function
  • Microbiology
  • Imaging


Essential Investigations required for specific consults
  • Fever ?focus: must have done: U/A, Urine MC&S, CXR, Bcx3 +/- respiratory viral swab
  • Skin and soft tissue infections: must have considered osteomyelitis (investigation history: X-ray/CT/MRI/bone scan), arterial &/or venous disease, DVT
  • IDC-associated UTI: urine sample needs to be collected via a fresh indwelling catheter immediately after insertion


Common problems in calls for consults
  • Check therapeutic guidelines before calling – eTG is available via CIAP. Many questions are answered here.
  • METo check & read our intranet guidelines, particularly the excellent document on vancomycin dosing
  • When a question relates to a bug with reported sensitivities and e.g. Oral options, it is worthwhile contacting the microbiology registrar first - they may have more options they can release


Extra tips for acquiring consults
  • Have the med chart, notes and PowerChart handy
  • If we are difficult to reach, leave your mobile number

 

Psychiatry

Common questions/reasons for consults to this Specialty
  • Depression
  • Suicide attempt
  • Possible psychogenic contribution
  • Decision-making capacity


General clinical information/questions relevant to consults to this Specialty
  • A clearly worded question whose answer will assist with the management of this patient.
  • A history relevant to the question
  • A basic mental state examination including basic cognitive testing.
  • Informing the patient that psychiatry have been asked to consult and an explanation of why.


Common question-specific information required
  • Depression: Does the person describe her mood as “depressed”? Has she got to the point where she has considered suicide?
  • Suicide attempt: What happened exactly when the person tried to kill himself? What was in his mind – was he hoping to die? Did he change his mind, or was his attempt frustrated by someone or something else? Having gotten to hospital is he still suicidal?
  • Possible psychogenic contribution: Aside from the fact that the any tests to done to date do not easily explain the patient’s symptoms, what positive factors have driven you to consider that the symptoms might be psychogenic?
  • Decision-making capacity: What reason do you have to doubt the standard presumption that adults are competent? Does the patient understand the information relevant to the decision? Can she use and weigh that information?


Background Medical History relevant to consults to this Specialty
(E.g. previous contact with Specialty, letters, reports, o/s travel, etc.)
  • Previous psychiatric contacts,
  • Previous admissions and
  • Previous treatments


Family/social history relevant to consults to this Specialty
Essential
  • Who is around to support the patient?
  • Who depends upon the patient for support?
  • If the patient has children, who is caring for them now?


Investigations relevant to consultations to this Specialty (and why)
  • FBC, UECs, LFTs, TFTs, RF, ANA (a number of simple medical conditions can either look exactly depression or impair a person’s capacity)
  • Urine drug screen (may be a differential diagnosis of psychosis, and must be done fairly early on in a person’s admission)


Common problems in calls for consults
Occasionally, RMOs seem surprised that we would require them to take a basic psychiatric history or do a basic mental state exam. Often they say, “Oh I haven’t done psychiatry for ages!” Psychiatry is just part of medicine, you should be doing it all the time. If you are not, it does not reflect well on your ability as a doctor. Please regard psychiatry consults in exactly the same way you would for a respiratory or infectious diseases consult. “Oh, I haven’t examined a chest for ages”, does not look too impressive.

Extra tips for acquiring consults
We are always eager to discuss the consult results directly with you. Please leave your name and pager number and or phone extension.

 

Drug Health

Common questions/reasons for consults to this Specialty
  • Intoxication
  • Drug/Alcohol withdrawal syndrome
  • D&A related pathology, e.g.: alcoholic liver disease, bacterial endocarditis from IDU (Injecting drug use)
  • Patient presents while on OST (Opioid Substitution Treatment) with any acute illness
  • Recurrent presentation with acute/chronic pain and drug-seeking suspected Altered mental state with a context of recent/chronic D&A use.
  • Unusual or unexplained bacterial pathology


General clinical information/questions relevant to consults to this Specialty
Essential
History of recent intake of Drugs and/or Alcohol: how much and how often for each substance in question. Hint: to quantify illicit drug use, ask about the dollar value used at street prices
  • Reason for presentation, history of presenting illness
  • General medical, surgical and psychiatric history
  • Basic examination with attention to clinical signs typical of Drug or Alcohol use.
  • Brief but careful MSE (mental state examination).
  • A clearly worded question posed to the D&A CL team to assist with diagnosis and/or treatment


  • Helpful
    • Long term history of Drug and Alcohol use
    • Social history
    • Results of recent Investigations/admissions performed outside WSLHD


    Common question-specific information required
    Intoxication:
    What are the clinical features that suggest this?

    Drug/Alcohol withdrawal syndrome:
    What are relevant signs and symptoms?

    D&A related pathology:
    What is the nature of the problem? Do you think Drug/Alcohol use is part of the aetiology?

    Patient presents while on OST:
    Which drug is the patient on (buprenorphine or methadone), what is the dose, when & where was the last dose given and who is the prescriber? Does the patients have active and/or old track marks in the cubital fossae, femoral and jugular regions?

    Acute/chronic pain:
    Is there demonstrable pathology to explain the pain? What is the pattern of drug requests? Why do you suspect drug-seeking?

    Altered mental state:
    What is the current mental state consistent with? Delirium, Dementia, Psychosis, Depression or other? How does recent D&A use relate to the mental state temporally?

    Bacterial pathology:
    Is there a history of IDU? Any fresh track marks? If the patient is on OST, is diversion suspected?

    Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc.)
    • Previous contact with D&A services.
    • Admissions to detox units and rehabilitation facilities.
    • Other medical treatment for D&A disorders in particular and other specialist reports and discharge summaries for other related and co-morbid conditions.


    Family/social history relevant to consults to this Specialty
    Essential
    • Where does the patient live and who with?
    • Does the patients have children in their care and if so, who is looking after them now?


    Helpful
    • What is the patient’s occupation/source of income?
    • Is the patient of CALD/Aboriginal background?
    • Does the patients have a forensic history? If so, when was the first and last stay in custody and total time spent in custody. Were the alleged offences due to Drug or Alcohol use?
    Medications relevant to consultations to this Specialty
    • All medications, especially all psychiatric and psychoactive drugs
    • S4 and S8 drugs
    • Medications specifically used to treat D&A disorders such as OST (as above) and anti-craving agents for alcohol dependency.
    • OTC preparations that can be misused, e.g.: Nurofen Plus, Unisom capsules


    Investigations relevant to consults to this Specialty
    • Urine drug screens (relevant to illicit and prescription drug use)
    • HBV, HCV, HIV serology and blood cultures when indicated (with a history of IDU)
    • General blood tests with attention to alcohol biomarkers: LFT’s, MCV, Plt count, Mg++, K+, albumin, INR (when chronic alcohol use suspected)
    • Blood or Breath alcohol level (always to be done when possible in the setting of intoxication). It is inadequate to avoid doing a BAL if other blood test are able to be performed.
    • ECG (to screen for prolonged QTc in patients on high dose methadone or in such patients with suspected VT/Torsades)


    Extra tips for acquiring consults
    • Take a history and perform an examination before calling for a consult.
    • Think: if overdose suspected, does Toxicology need to be contacted? If MSE abnormal, does the Mental Health team need to be involved?


    Common problems in calls for consults
    • Not knowing who to call and when
    • Calling without a basic assessment performed beforehand
    • Not calling when it could be helpful
      • 
Not calling to avoid disturbing the Dr on call (service is on call 24/7) when prompt advice might help
    • Calling for a consult when the patient has been in hospital for days and discharge is imminent
    • No clear rationale for the consult

     

    Intensive Care Unit

    Ward staff requiring urgent review of deteriorating patients, must initiate an MET call via the Hospital switchboard. The switchboard will then issue an ‘MET call’ via the emergency paging system. This will send a message for the MET team to attend urgently. The MET team is comprised of the Medical Registrar (MET Team Leader), Anaesthetic Registrar and the ICU Registrar.

    During the day, the ICU Registrar who is carrying the MET pager will attend the MET/cardiac arrest/trauma call. The ICU Senior Registrar need only attend as a back-up if required by the ICU Registrar.

    At night, one of the Night Registrars, will carry the MET pager and attend the MET / cardiac arrest.

    All Emergency Department, Operating Theatre and Out-of-Hospital initiated referral calls to ICU should be passed to the senior registrar on 7571, 24 hours a day, 7 days a week.

    In business hours, this will be answered by the on-site ICU Senior Registrar (SR) After-hours the SR will review or call in person. If the SR is offsite he will ask the registrar to review and liaise regarding the potential admission to the ICU.

    An exception to the rule of urgent review is as follows. For ward patients admitted under a specialist, an ICU Consultation can be initiated by someone of Registrar level or above by contacting the ICU Senior Registrar (pager via switch) 24/7 on 7571.This referral must never be delegated to a more junior member of the referring medical team or ICU team. The Registrar must have first discussed the need for referral to ICU with the primary Consultant (or the designated on-call Consultant for that particular specialty or sub-specialty).

    If the patient is unwell and breaches the calling criteria after the referral then and MET call should be initiated. Referral is not a substitute for MET. And Urgent reviews would warrant a clinical review or MET as deemed appropriate by the team.

    Any patient in whom 2 or more MET calls have been made within 24 hours or the teams are concerned must be discussed with an ICU Consultant.

    IT IS NOT ADVISABLE FOR TEAMS TO RING THE ICU DIRECTLY TO SPEAK TO an ICU Registrar as it affects the clinical work and does not identify the right person. This can be used to escalate if the pager has not been answered for whatever reasons.

     

    Infectious Diseases

    Common questions/reasons for consults to this Specialty
    • Empiric antibiotic therapy
    • Targeted antibiotic therapy
    • Duration of antibiotic therapy
    • Fever ?source
    • Post-Acute Community Care (PACC) intravenous antibiotics


    General clinical information/questions relevant to consults to this Specialty
    • Fever – onset, course
    • Septic screen – UA, urine MC&S, CXR, Bcx3
    • Imaging results
    • Previous and current microbiology results – source, bugs & sensitivities
    • Antibiotic therapy – IV & PO drug, dose, dates, reason for changing


    Common question-specific information required
    • What surgery has occurred, what were the intra-operative findings?
    • What surgery is planned?
    • What immunosuppression have they received?
    • How long have they been neutropaenic, how long are they expected to be neutropaenic?


    Background Medical History relevant to consults to this Specialty
    (E.g. previous contact with Specialty, letters, reports, o/s travel, etc.)

    Essential
    • Allergies – what reaction & when?
    • Asplenia
    • Which infectious Diseases specialists have they seen & when – obtain letters
    • Microbiology reports – chase sensitivities


    Context-specific
    • Sick contacts
    • Overseas travel – locations, duration, accommodation, activities, health-care contact
    • Bush contact
    • Animal contact


    Family/social history relevant to consults to this Specialty
    Essential
  • Occupation
  • Smoking


  • Helpful
    • Vaccinations
    • IVDU
    • Sexual history


    Medications relevant to consultations to this Specialty
      AntimicrobiMET
    • Immunosuppressant’s
    • Insulin
    • Warfarin & other drugs with interactions
    • over-the-counter medications


    Essential Investigations required for specific consults
    • Fever ?focus: must have done: U/A, Urine MC&S, CXR, Bcx3 +/- respiratory viral swab
    • Skin and soft tissue infections: must have considered osteomyelitis (investigation history: X-ray/CT/MRI/bone scan), arterial &/or venous disease, DVT
    • IDC-associated UTI: urine sample needs to be collected via a fresh indwelling catheter immediately after insertion


    Common problems in calls for consults
    • Check therapeutic guidelines before calling – eTG is available via CIAP. Many questions are answered here.
    • METo check & read our intranet guidelines, particularly the excellent document on vancomycin dosing
    • When a question relates to a bug with reported sensitivities and e.g. Oral options, it is worthwhile contacting the microbiology registrar first - they may have more options they can release


    Extra tips for acquiring consults
    • Have the med chart, notes and PowerChart handy
    • If we are difficult to reach, leave your mobile number

     

    Psychiatry

    Common questions/reasons for consults to this Specialty
    • Depression
    • Suicide attempt
    • Possible psychogenic contribution
    • Decision-making capacity


    General clinical information/questions relevant to consults to this Specialty
    • A clearly worded question whose answer will assist with the management of this patient.
    • A history relevant to the question
    • A basic mental state examination including basic cognitive testing.
    • Informing the patient that psychiatry have been asked to consult and an explanation of why.


    Common question-specific information required
    • Depression: Does the person describe her mood as “depressed”? Has she got to the point where she has considered suicide?
    • Suicide attempt: What happened exactly when the person tried to kill himself? What was in his mind – was he hoping to die? Did he change his mind, or was his attempt frustrated by someone or something else? Having gotten to hospital is he still suicidal?
    • Possible psychogenic contribution: Aside from the fact that the any tests to done to date do not easily explain the patient’s symptoms, what positive factors have driven you to consider that the symptoms might be psychogenic?
    • Decision-making capacity: What reason do you have to doubt the standard presumption that adults are competent? Does the patient understand the information relevant to the decision? Can she use and weigh that information?


    Background Medical History relevant to consults to this Specialty
    (E.g. previous contact with Specialty, letters, reports, o/s travel, etc.)
    Previous psychiatric contacts,
  • Previous admissions and
  • Previous treatments


  • Family/social history relevant to consults to this Specialty
    Essential
    • Who is around to support the patient?
    • Who depends upon the patient for support?
    • If the patient has children, who is caring for them now?


    Investigations relevant to consultations to this Specialty (and why)
    • FBC, UECs, LFTs, TFTs, RF, ANA (a number of simple medical conditions can either look exactly depression or impair a person’s capacity)
    • Urine drug screen (may be a differential diagnosis of psychosis, and must be done fairly early on in a person’s admission)


    Common problems in calls for consults

    Occasionally, RMOs seem surprised that we would require them to take a basic psychiatric history or do a basic mental state exam. Often they say, “Oh I haven’t done psychiatry for ages!” Psychiatry is just part of medicine, you should be doing it all the time. If you are not, it does not reflect well on your ability as a doctor. Please regard psychiatry consults in exactly the same way you would for a respiratory or infectious diseases consult. “Oh, I haven’t examined a chest for ages”, does not look too impressive.

    Extra tips for acquiring consults

    We are always eager to discuss the consult results directly with you. Please leave your name and pager number and or phone extension.

     

    Palliative and Support Care

    Supportive & Palliative Medicine team involvement is not only for patients with cancer and patients in the last few hours/days of life. A referral is relevant for any patient with a life-threatening illness at any stage.

    Please fill out the eConsult form found under Power Orders on Powerchart AND phone the Palliative Care Advanced Trainee to discuss the referral.

    Common questions/reasons for consults to this Specialty
    • Difficult symptom management in anyone with life-threatening illness, e.g. pain, dyspnoea, anxiety, nausea and vomiting. Symptom control e.g. pain, nausea
    • Decision-making in complex life threatening illness where the outcome is uncertain
    • Specific information regarding PCU and complex discharge
    • End of life care
    • Take over care
    • Community “link up” NOT A HELPFUL REASON FOR CONSULT and should be discussed with the Palliative Care CNC on pager, Blacktown #7584 or mobile 0407820081, Mt Druitt 0438 024 768
    • Advanced care planning discussions


    General clinical information/questions relevant to consults to this Specialty
    Essential
    • Diagnosis
    • Prognosis
    • Patient and family understanding of diagnosis and stage
    • Patient and family understanding of goMET of care
    • Patient and family aware of referral
    • Reason for referral
      • Symptom control – e.g. pain, nausea/vomiting, constipation etc.
      • End of life care
      • Discharge planning
      • Assistance with discharge planning


    Helpful
    • Family dynamic
    • Social situation
    • Community support


    Common question-specific information required
    • Reason for referral – often the referring Dr e.g. intern has no idea
    • Therapies during the admission (e.g. chest drain, radiotherapy, medications)
    • Has an advanced medical plan been completed?


    Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc.)
    Essential
    • Current services/clinicians involved in patient’s care
    • Summary of course of the illness (treatments/interventions, results of latest investigations)
    • The services/clinicians involved in patient’s care and whether the patient is known to Supportive & Palliative Medicine service already and which consultant was the treating doctor
    • Co-morbidities impacting on current illness
    • Functional status prior to admission


    Family/social history relevant to consults to this Specialty
    Essential
    • Family / social supports
    • Major family dynamic/discord impacting on care
    • If discharge home is planned, are there adequate supports in place
    • If discharge home is planned, has a community nursing referral been made? DO NOT wait until day of discharge and DO NOT expect the Supportive & Palliative Medicine service to do this. Palliative Care CNC can provide advice regarding community referrMET.


    Medications relevant to consultations to this Specialty Analgesics
  • Anti-emetics
  • Aperients


  • Investigations relevant to consultations to this Specialty
    • EUC, LFT, FBC
    • In patients with advanced malignancies presenting with delirium/constipation or uncontrolled pain
      • Corrected Calcium
    • AXR if constipated
    • Recent staging scans


    Investigations relevant to consultations to this Specialty (and why)
    • AXR for constipation, (especially when history is in keeping with long standing
    • Constipation but negative PR), rule out SBO
    • Renal function, very important when choosing appropriate opiates
    • Corrected Calcium if delirium, constipated or uncontrolled pain
    • Results of latest staging scan for patients with cancer to help determine overall disease burden and cause of symptoms


    Common problems in calls for consults
    • Reason for referral – often the referring Dr e.g. intern has no idea
    • No clear goMET of care
    • No advanced medical plan completed
    • Referring team often expect Pall Care to have the advanced medical plan discussions. This is the responsibility of the treating team. Pall Care can ASSIST with these discussions, NOT lead or do them.
    • No e-Consult request sheet completed


    Extra tips for acquiring consults
    • Know why the consult has been requested
    • Give an appropriate clinical picture to the registrar taking the call
    • Have all relevant clinical information at hand when phoning so can quickly answer questions, especially the medication chart and have PowerChart open
    • If patient is to be discharged to a Residential Aged Care/Nursing Home, call the CNC Aged Care Sharon Sutherland, and refer through community health intake/ CRS to Palliative Care Nurse Practitioner Deb McLaren on 98817789 using the community nursing discharge form
    • If advice is only concerning home discharge planning, page the Palliative Care CNC Helen Smith on 0407 820 081 #7548 for advice. The CNC will NOT do the discharge planning, referrMET to community nursing etc. This is the responsibility of the treating team.
    • If patient is to be discharged to a ACF/Nursing Home, refer to the Palliative Care ACF outreach CNS Ray Wilcox 0419 335 667 (Parramatta, Auburn, Holroyd, Hills LGA’s) or Pall Care Nurse Practitioner Deborah McLaren 0429 551 928 (Blacktown Mt Druitt LGA’s)
    • If advice is only concerning home discharge planning, page the Palliative Care CNC Helen Smith #7548. This is for advice. The CNC will NOT do the discharge planning, referrMET to community nursing etc. This is the responsibility of the treating team.
    • Supportive & Palliative Medicine service ARE NOT discharge planners. This is the responsibility of the treating team. Supportive & Palliative Medicine service are happy to give advice how to provide community support and follow up
    • No e consult request completed before the phone call to registrar. Supportive and Palliative Medicine need a medical e-consult request before they will see a patient.
    • Not knowing the reason for referral – often the referring JMO e.g. intern has no idea
    • No clear goMET of care have been documented in notes
    • No Adult Resuscitation Plan / Advanced Medical Plan has been completed by treating team
    • Referring team often expect Palliative Care to have the advanced medical plan discussions. This is the responsibility of the treating team. Palliative Care can ASSIST with these discussions, NOT lead or do them.
    • Expecting Palliative Care to take over care of, or to transfer to the Palliative Care Unit patients with non- complex dying in the last days of life.
    • Referring people with chronic pain problems. They should be referred to the chronic pain service, not Palliative Care.

     

    Colorectal Surgery

    Common questions/reasons for consults to this Specialty
    • Large Bowel Obstruction
    • Colorectal Cancer
    • Stoma issues
    • Diverticulitis


    General clinical information/questions relevant to consults to this Specialty
    Essential
    • Past history of related disease
    • Previous colonoscopy / surgical resection
    • Family history
    • Known to a colorectal surgeon?


    Helpful
    • Past medical history
    • Quality of life (? Independent/ NH resident)


    Common question-specific information required
    • Duration of illness
    • Imaging to confirm diagnosis (AXR/CT)
    • Previous interventions (scopes/operation)


    Background Medical History relevant to consults to this Specialty
    (E.g. previous contact with Specialty, letters, reports, o/s travel, etc.)
    • Letters
    • Pathology reports
    • ? Localised / metastatic disease
    • Any treatment elsewhere and the plan (Is the patient known to an oncologist?)


    Family/social history relevant to consults to this Specialty
    • Cancer/genetic history
    • Inflammatory bowel disease
    • Other related familial syndromes
    • Smoker for Crohn’s disease


    Medications relevant to consultations to this Specialty
    • Anticoagulant
    • Chemotherapy (especially VEGF inhibitors)
    • Radiotherapy in past
    • Immunotherapy


    Investigations relevant to consultations to this Specialty
    • Bloods (Hb, electrolytes, iron studies, CEA, LFTs)
    • AXR
    • CT
    • Gastrograffin studies


    Essential Investigations required for specific consults
    • Bloods
    • Imaging to aid confirming diagnosis

     

    Respiratory

    Common questions/reasons for consults to this Specialty
    • Shortness of breath
    • Increased oxygen requirements
    • Suspected pneumonia or treatment of pneumonia
    • Abnormal chest radiology (including lung masses)
    • Sleep disorders
    • Suspected pulmonary embolism
    • ?need bronchoscopy
    • ?need pleural procedure (pleural effusion)

     

    General clinical information/questions relevant to consults to this Specialty
    Essential
    • Presence of dyspnoea/wheeze/cough/sputum production/haemoptysis/chest pain/oedema/fever
    • Physical examination: Oxygen saturations, respiratory rate, temperature, GCS, raised JVP, wheeze, crepitation’s, bronchial breathing, and peripheral oedema
    • Relevant history of respiratory disease (COPD, lung fibrosis, bronchiectasis, pulmonary hypertension, lung cancer, etc.)

     

    Helpful
    • Prior need for intubation or non-invasive ventilation
    • Current cognition compared to baseline and ability to make decisions
    • Usual functional status

     

    Common question-specific information required
    • If possible sleep apnoea: does patient have confirmed sleep apnoea, diagnosed when/where/by whom, on CPAP therapy or not, do they have their CPAP machine with them, is patient commercial vehicle driver, has patient had a MVA or near-miss due to sleepiness, is patient willing to have sleep study and/or wear CPAP mask if required
    • If suspected PE: prior VTE, current and prior anticoagulation, Wells’ criteria, haemodynamic stability, contraindications to anticoagulation, history of COPD/renal failure, ECG
    • If suspected pneumonia or COPD exacerbation: productive cough, fevers, number of exacerbations, prior resistant organisms (e.g.-pseudomonas), risk factors for aspiration, spirometry
    • If abnormal lung radiology: changes compared to last imaging, is imaging on Cerner or via outside radiology, if outside radiology can the patient please have the films with them
    • ? Need bronchoscopy: recent chest imaging (recent CT chest/HRCT chest), previous procedures (bronchoscopy, induced sputum, sputum culture, pleural procedure), sedative risk (e.g. current spirometry, ABG), coagulation status (renal impairment, thrombocytopaenia, aspirin, clopidogrel, clexane, warfarin, rivaroxaban etc.)
    • Management of pleural effusion: results of previous pleural procedures, serial chest imaging if available, cardiac history, respiratory symptoms, coagulation status (renal impairment, thrombocytopaenia, aspirin, clopidogrel, clexane, any anticoagulants etc.)

     

    Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc.)
    Essential
    • Previous letters from respiratory consultants
    • Previous pulmonary function tests (on Powerchart if done at Westmead)
    • Reports from ALL previous sleep studies if off-site
    • Prior blood gases demonstrating elevated CO2
    • Prior imaging (especially if imaging now abnormal)
    • Is advanced medical planning in place?

     

    Helpful
    • Prior known respiratory specialist, letters and investigations (including CT chest, PFT, TTE)
    • Functional status
    • Exercise tolerance

     

    Family/social history relevant to consults to this Specialty
    Essential
    • Smoking history (including second-hand smoke)
    • Occupational History
    • Asbestos exposure
    • Living situation (nursing home or at home)

     

    Helpful
    • Pets, bird exposure, unusual hobbies
    • Medications relevant to consultations to this Specialty
    • Steroids
    • Diuretics
    • Bronchodilators - have puffers by bedside
    • Antibiotics
    • Immunosuppressive’s Anticoagulation (including prophylactic)

     

    Investigations relevant to consultations to this Specialty
    • Spirometry
    • Arterial Blood Gas
    • Chest X-ray (CT if available)
    • Compare new findings to old radiology
    • Echocardiogram
    • ECG

     

    Essential Investigations required for specific consults
    • Shortness of breath: spirometry, ABG, chest X-ray, baseline bloods, ECG
    • Increased oxygen requirement: ABG, spirometry, chest X-ray, baseline bloods including FBC, UEC, LFT, CRP and ECG
    • Suspected PE: Chest X-ray, ABG, ECG
    • Suspected or treatment of pneumonia: ABG, chest X-ray, baseline bloods including FBC, UEC, LFT, and CRP
    • Abnormal chest radiology: prior imaging must be chased, as well as prior biopsies if applicable
    • Sleep disorders: ABG if significant obstructive sleep apnoea suspected or BMI >40kg/m2
    • ?Need for bronchoscopy: spirometry, ABG, coagulation profile, platelet, CXR, recent imaging with either CT chest or HRCT chest
    • Management of Pleural Effusion: CXR within 24 hours of consult, coagulation profile, platelet count Investigations relevant to consultations to this Specialty (and why)
    • Spirometry (to confirm or exclude obstructive or restrictive defect)
    • Arterial Blood Gas (to confirm level of hypoxaemia, assess for hypercapnia, and assess metabolic compensation)
    • Chest X-ray (to diagnose pulmonary pathologies)
    • ECG to exclude concomitant cardiac pathology and for signs of pulmonary hypertension

     

    Common problems in calls for consults
    • Old information not obtained (e.g. long standing radiological changes not requiring further investigation)
    • No imaging obtained prior to consult
    • No recent spirometry
    • No ABG performed. A VBG is not adequate.

     

    Consultation for consideration of pleural aspirate/drain insertion, but with the most recent CXR performed 3-4 days prior to the consultation

     

    Orthopaedics

    Common questions/reasons for consults to this Specialty
    • Trauma
    • Tumour
    • Septic arthritis
    • Spinal injury

     

    General clinical information/questions relevant to consults to this Specialty
    Essential
    • Age
    • Injury
    • Mechanism of injury
    • Injury open / closed / dislocated
    • Neurovascular status
    • Underlying pathology (e.g. Pathological Fracture, etc.)
    • Medical comorbidities
    • Other injuries

     

    Helpful
    • Anticoagulation status
    • Vital Signs: Stable / unstable in resuscitation bay in ED
    • Bloods

     

    Common question-specific information required
    Essential
    • Obvious X-ray findings
    • Routine Bloods
    • ESR /CRP if Sepsis considered
    • Microscopy results if joint aspirate done
    • Neurological deficit and mobility

     

    Background Medical History relevant to consults to this Specialty (E.g. previous contact with Specialty, letters, reports, o/s travel, etc.)
    Helpful
    • Prognosis
    • Recurrence
    • Other teams involved

     

    Family/social history relevant to consults to this Specialty
    Essential
    • Living arrangements and family support
    • Family/patient - history/Consent
    • Smoking Status
    • Alcohol dependence
    • Drug dependence
    Helpful
    • Occupation

     

    Medications relevant to consultations to this Specialty
    • Warfarin
    • Clopidogrel
    • Aspirin
    • Antibiotics

     

    Essential Investigations relevant to consultations to this Specialty
    • XR
    • FBC/EUC
    • . CRP/ESR if Infection suspected

     

    Essential Investigations required for specific consults
    • CT / US if required
    • Joint Aspirate
    • CT if joint involvement in major bone

     

    Investigations often requested (and why)
    • XR / CT to detail bony injury
    • FBC/ EUC/ / Coagulation studies likely for preoperative workup
    • ESR/ CRP
    • MRI to identify ligamentous injury

     

    Common problems in calls for consults
    • History not clear.
    • Basic investigations not done.
    • Need to state primary reason for consult

     

    Extra tips for acquiring consults
    • Ask earlier in day when there is time to get required information and have required info so that initial plan can be started.

     

    Obstetrics and Gynaecology

    Common questions/reasons for consults to this Specialty
    • Unusual PV bleeding
    • Pelvic Pain
    • Vaginal discharge
    • Vaginal/vulval lumps
    • Pelvic organ prolapse
    • Pelvic mass found on CT/USS

     

    General clinical information/questions relevant to consults to this Specialty
    Essential
    • Menstrual history incl. LMP
    • Sexually active?
    • Pregnancy status
    • Past obstetric and gynaecological history incl. surgery
    • Pap history

     

    Helpful
    • Contraception? What type?
    • Systemic symptoms

     

    Background Medical History relevant to consults to this Specialty
    (E.g. previous contact with Specialty, letters, reports, o/s travel, etc.)
    Essential
    • Previously seen O & G? Why? Treatment?
    • Previous Pap and/or STI check
    • Previous USS?

     

    Family/social history relevant to consults to this Specialty
    Essential
    • Family history of uterine/ovarian/breast/bowel cancer
    • Medications relevant to consultations to this Specialty
    • Contraception
    • Fertility treatments
    • HRT

     

    Investigations relevant to consultations to this Specialty
    • Serum or urine BHCG
    • Pelvic USS (TV preferred)
    • FBC (if PVB)
    • CRP (if ?PID)
    • Tamoxifen

     

    Essential Investigations required for specific consults
    • As above

     

    Investigations relevant to consultations to this Specialty (and why)
    • Tumour markers (specific for age and type of pelvic mass)
    • USS
    • BHCG

     

    Common problems in calls for consults
    One needs consent to perform PV exam!!! If a patient is unable to consent please arrange family/guardian consent PRIOR to requesting the consult. Do NOT leave it up to the O&G Registrar to organise this on your behalf as it can take days to chase the family.

    Similarly, if the patient can consent please make sure that she is aware that an internal examination may be performed and is happy to have one done on the ward. This is particularly important if the consult is for a non-urgent reason or may be alternatively managed as an outpatient

     

    Breast Surgery

    Common questions/reasons for consults to this Specialty
    • Breast Abscess
    • Breast Lump/Lesion
    • Nipple discharge
    • Mastalgia

     

    General clinical information/questions relevant to consults to this Specialty
    Essential
    • Findings on examination of breast: Site/size/skin change/tenderness/mobile/fixed/palpable/impalpable
    • Findings on examination of axillae (i.e. lymphadenopathy)
    • Last mammogram/breast ultrasound (incl. date and results)
    • Previous history of breast disease (incl. date, diagnosis and treatment)
    • Family history of breast/ovarian cancer (need to include approximate age of diagnosis as well)
    • Smoking history

     

    Helpful
    • Medical/Surgical history
    • Medications
    • Pregnancy history

     

    Common question-specific information required
    Breast Abscess:
    • Findings on examination of breast/axillae
    • Last mammogram/ultrasound
    • Associated nipple discharge
    • Any history of previous abscess - treatment/where/when
    • Systemic symptoms (fever, nausea, weight loss etc.)
    • Smoking history
    • Breastfeeding/number of weeks postpartum
    • Systemic symptoms

     

    Breast Lump/Lesion:
    • Findings on examination of breast/axillae
    • Last mammogram/ultrasound
    • Associated nipple discharge/inversion
    • Any previous history of breast disease in general
    • Family history of breast/ovarian cancer
    • Medications (particularly HRT)
    • Results of biopsies (if taken already)
    • Smoking history

     

    Nipple discharge:
    • Findings on examination of breast/axillae
    • Last mammogram/ultrasound
    • Characteristics of discharge - colour/blood-stained/
    • Smell/spontaneous or on expression only
    • Any previous history of breast disease in general
    • Family history of breast/ovarian cancer
    • Medications (particularly HRT)
    • Smoking history

     

    Mastalgia:
    • Characteristics of pain: bilateral/unilateral; Cyclical/constant; diffuse/local; stabbing/burning/ache etc.
    • Findings on examination of breast/axillae
    • Last mammogram/ultrasound
    • Any previous history of breast disease in general
    • Family history of breast/ovarian cancer
    • Medications (particularly HRT)
    • Smoking history

     

    Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc.)
    Essential
    • Previous history of breast disease (incl. date, diagnosis and treatment)
    Helpful
    • Hormonal history:
    • Menopausal status (pre/peri/post)
    • Age of menarche
    • Pregnancy history
    • Current/previous HRT
    • General medical history
    • Surgical history
    • Medications


    Family/social history relevant to consults to this Specialty
    Essential
    • Family history of breast or ovarian cancer
    Helpful
    • Family history of other cancers
    • Smoking/alcohol history
    • Social supports

     

    Medications relevant to consultations to this Specialty
    • Antibiotics
    • Steroids/immunosuppression
    • Current/previous HRT
    • Oral contraceptive pill

     

    Investigations relevant to consults to this Specialty
    • Mammogram
    • Breast ultrasound
    • Biopsies

     

    Essential Investigations required for specific consults
    Breast Lump/Lesion
    • Mammogram
    • Breast Ultrasound

     

    Breast Abscess:
    • FBC
    • Previous culture results (if available)
    • Breast ultrasound

     

    Investigations relevant to consultations to this Specialty (and why)
    Imaging of the breast:
    • A breast lesion requires imaging that includes a mammogram and ultrasound
    • A breast abscess requires imaging that includes an ultrasound only
    • These are requested if they have not been requested already by the referring team

     

    Biopsies of the breast lesion:
    • The breast team will make an assessment of whether a lesion needs to be biopsied or not if the radiologist has not made this assessment already.

     

    Toxicology

    Common questions/reasons for consults to this Specialty
    • Is this dose of paracetamol likely to cause hepatotoxicity? When is the paracetamol nomogram appropriately used?
    • Could this level indicate digoxin or lithium toxicity
    • What are the symptoms and signs of serotonin toxicity? How is serotonin toxicity differentiated from neuroleptic malignant syndrome?
    • Is this patient’s delirium drug-induced?

     

    General clinical information/questions relevant to consults to this Specialty
    Essential
    • Drug(s) ingested or exposed to
    • Dose, route, timing
    • Acute single ingestion or staggered?
    • Relevant drug levels
    • Renal & liver function tests

     

    Helpful
    • Neurological exam (incl. pupils, clonus, tone, reflexes), vital signs

     

    Background Medical History relevant to consults to this Specialty
    (E.g. previous contact with Specialty, letters, reports, o/s travel, etc.)
    Essential
    • Medication list
    • Adverse drug reactions and allergies
    • Previous mental health admissions or issues
    • Prior drug overdoses

     

    Helpful
    • Recreational drug use history
    • Opioid substitution program history

     

    Family/social history relevant to consults to this Specialty
    Essential
    • Home situation & support systems

     

    Helpful
    • Occupation and occupational drug/chemical exposure

     

    Medications relevant to consultations to this Specialty
    • Analgesics
    • Over-the-counter preparations
    • Traditional medicines
    • Psychotropic drugs, incl. anti-depressants, sedatives & neuroleptics
    • Cardiac drugs
    • Anticoagulants

     

    Investigations relevant to consults to this Specialty
    • Renal function and electrolytes
    • Liver function tests
    • Urine drug screen in certain cases
    • Venous blood gas
    • Blood glucose level in all patients with altered level of consciousness
    • ECG – cardiac drugs, psychotropic’s, analgesics
    • βHCG – women of child-bearing age

     

    Essential Investigations required for specific consults
    • Paracetamol level and other specific drug levels
    • Snake bite: fibrinogen, coagulation profile, D-Dimer, CK

     

    Investigations relevant to consultations to this Specialty (and why)

     

    Extra tips for acquiring consults
    • Just call us!

     

    Common problems in calls for consults
    • Inadequate drug history
    • Inadequate neurological exam
    • Inability to detect delirium
    • Ordering inappropriate drug levels

     

    Ear, Nose and Throat Surgery

    Common questions/reasons for consults to this Specialty
    • ED: epistaxis, post-tonsillectomy bleed, sore throat, ear pain

     

    General clinical information/questions relevant to consults to this Specialty
    History
    • Epistaxis: anterior/posterior bleed, blood pressure, anticoagulants
    • Sore throat: tolerating oral solid/fluids/saliva, fevers, respiratory distress? Quinsy (trismus, hot potato voice)
    • Ear pain: discharge, hearing loss, vertigo, facial nerve weakness, recent URTI
    • Post-tonsillectomy bleed: day post-op, amount of blood loss, haemodynamics

     

    Examination
    • Epistaxis: nasal cavity ?bleeding point, oral cavity ?blood in posterior oropharynx
    • Sore throat: oral cavity (trismus, tonsillar enlargement, uvula midline/deviated, soft palate swelling/erythema), cervical lymphadenopathy, neck swelling, restriction neck ROM
    • Otalgia: external ear canal (oedema, discharge), pinna (swelling, pain on traction), TM (intact/perforated, acute otitis media)
    • Post-tonsillectomy bleed: oral cavity (bleeding point, active bleeding/clot visible)

     

    Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc.)
    Epistaxis: anticoagulation (reason), previous nasal surgery, history of trauma, known coagulopathy
    Sore throat: associated URTI illness, previous episodes of tonsillitis/EBV/quinsy, smoking history
    Ear pain: Recent URTI, recent water exposure/trauma, immunocompromised
    Family/social history relevant to consults to this Specialty
    • Smoking history
    • Alcohol history

     

    Medications relevant to consultations to this Specialty
    • Previous duration/course of antibiotics
    • Anticoagulants
    • Immunosuppressive medications
    • Ototoxic medications

     

    Investigations relevant to consultations to this Specialty
    Epistaxis/Post-tonsillectomy bleed:
    • Bloods: FBC, UEC, Coags, Group and Hold

    Sore Throat:
    • Bloods: FBC, UEC, LFT, CRP, Monospot test/EBV serology (as indicated)

    Ear pain:
    • Previous swab M/C/S

    Investigations relevant to consultations to this Specialty (and why)
    • Lateral X-ray Airways (?foreign body)
    • CT Petrous Temporal Bone- if you are concerned about an otological problem
    • + CT Brain with contrast (mastoiditis)
    • CT Paranasal Sinuses
    • CT Neck with contrast
    • US Neck (salivary gland infection/collection)

     

    Common problems in calls for consults

     

    History
    • Full characterisation of the complaint: onset, character, duration, severity, triggering/exacerbating factors, relieving factors, previous treatment
    • Addressing treatable symptoms in ED e.g. pain, dehydration

     

    Examination
    • Oral cavity: proper description of tonsil size/appearance, uvula midline/deviated and presence of soft palate swelling
    • Ear: often not examined before consulting ENT, tuning fork tests

     

    Extra tips for acquiring consults
    • Attempt to examine the ear, nose or throat first. ENT team will be much more receptive if you have had a look and have some findings to report!
    • Take a full history and if the information is incomplete, consult the notes or GP letters to find out further information
    • Take blood tests promptly and have results ready before making an ENT referral- this will help the team decide on the urgency of the presentation and to institute appropriate management early.

     

    Head and Neck Surgical Oncology

    Common questions/reasons for consults to this Specialty 
    • Lymph node biopsy 
    • Thyroid nodules 
    • Soft tissue tumours 
    • Skin lesions (Melanoma/SCC) 

     

    General clinical information/questions relevant to consults to this Specialty 
    Lymph node 
    • Reason for biopsy 
    • Timing of biopsy - We don’t have extra operating time to perform biopsy immediately. Each time a biopsy is required we need to move a patient on the waiting list. Give an idea based on the clinical needs of the patient e.g. within 1 week (Burkett’s lymphoma), within 1 month (low grade lymphoma). Ask the consultant in charge prior to calling 

     

    Thyroid nodule 
    Symptoms: 
    • Hyperthyroidism/hypothyroidism 
    • Obstructive symptoms –dysphagia, shortness of breath, voice change 
    • How it was found (most are incidental) 
    • Cervical lymphadenopathy 

     

    Skin lesions 
    • Clinical assessment of lesion (what do you think it is) 
    • Local lymph node involvement 

     

    Soft tissue tumour 
    • How long present 
    • Change in size 
    • Symptoms 
    • Neurovascular involvement clinically 

     

    Common question-specific information required 
    • Lymph node biopsy we prefer to perform under general anaesthetic particularly if they are deep, cervical or not palpable 
    • Mesenteric lymph nodes can be biopsied laparoscopically 
    • Retroperitoneal lymph nodes generally can NOT be biopsied laparoscopically. They are much better accessed via image guided core biopsy or even EUS depending on location. Surgical approach usually means a laparotomy or at least mini-laparotomy. Sometimes patient may require a general anaesthetic or at least sedation for the core biopsy to ensure they don’t move during the procedure. 

     

    Background Medical History relevant to consults to this Specialty 
    (E.g. previous contact with specialty, letters, reports, o/s travel, etc.
    Helpful 
    • Medical fitness for surgery (Skin lesions can be excised under local anaesthetic)

     

    Medications relevant to consultations to this Specialty 
    • Blood thinners

     

    Essential Investigations required for specific consults 
    Lymph node biopsy 
    • Imaging (ideally CT) 
    • FBC – some patients are pancytopaenic which needs correction prior to surgery 

     

    Thyroid nodules 
    • TFT/CMP 
    • Thyroid US 
    • FNA (prefer Austpath) 

     

    Skin lesions 
    • Usually nil unless clinical signs of lymph node involvement 

     

    Soft tissue tumours 
    • CT/MRI of region of concern 
    • Do NOT arrange core biopsy unless asked 

     

    Investigations relevant to consultations to this Specialty (and why) 
    • Lymph node biopsy 
    • If special tests are required beyond histology/flow cytometry, team needs to specify prior to surgery 

     

    Extra tips for acquiring consults 
    • Be clear on the reason for the consult (ideally in the first sentence)

    Plastic Surgery

    Common questions/reasons for consults to this Specialty 
    • Hand injuries 
    • Wounds 
    • Facial trauma 
    • Facial swelling of non-dental origin 

     

    General clinical information/questions relevant to consults to this Specialty 
    Essential 
    • Reason for presentation/admission 
    • Comorbidities 
    • Imaging results 

     

    Common question-specific information required 
    • Hand dominance 
    • Work cover injury or not – will determine where patient gets surgery 
    • Age of injury – will determine timing of surgery 
    • Mechanism of injury 
    • Open or closed fracture 

     

    Background Medical History relevant to consults to this Specialty 
    (E.g. previous contact with Specialty, letters, reports, o/s travel, etc.) 
    Essential 
    • Comorbidities: DM, immunosuppression 
    • Smoker? 

     

    Family/social history relevant to consults to this Specialty 
    Essential 
    • Nature of employment 
    • Family support, ability to care for wounds at home? 

     

    Medications relevant to consultations to this Specialty 
    • Immunosuppressant’s 
    • Antibiotics 
    • ADT up-to-date? 

     

    Investigations relevant to consultations to this Specialty 
    • X-ray 
    • CT 

     

    Essential Investigations required for specific consults 
    • X-ray for hand injuries 
    • OPG and PA mandible for mandibular fractures 
    • CT facial bones for facial fractures (sometimes require 3D recon) 

     

    Investigations relevant to consultations to this Specialty (and why) 
    • X-ray 
    • OPG and PA mandible – to get 3D appreciation of mandibular fracture 

     

    Common problems in calls for consults 
    • Unable to describe fracture on x-ray (stating ”the MCPJ or ICPJ looks funny” IS NOT OK)

     

    Upper GI Surgery

    Common questions/reasons for consults to this Specialty 
    • UGI consults 
    • Gallbladder pathology 
    • Feeding tubes 

     

    General clinical information/questions relevant to consults to this Specialty 
    Essential 
    • Demographics 
    • Reason for consult (!) 
    • Previous surgical history (important) 
    • Functional status, quality of life 
    • Medical comorbidities 

     

    Helpful 
    • Copy of operation reports 
    • Known to surgeons? 
    • Investigations so far 

     

    Common question-specific information required 
    • Chronic hepatitis (for HCC) 
    • Scopes (for CRC liver metastases) 
    • ERCP (for bile duct strictures) 
    • Are patients MRI safe? 
    • Nutritional status 

     

    Background Medical History relevant to consults to this Specialty 
    (E.g. previous contact with specialty, letters, reports, o/s travel, etc.).
    Essential 
    • Operation reports 
    • Results of previous investigations (films or CD please) 

     

    Family/social history relevant to consults to this Specialty 
    Essential 
    • Premorbid function 
    • Does patient/family want an operation 

     

    Medications relevant to consultations to this Specialty 
    • Anticoagulants 
    • Antiplatelet medications 
    • Immunosuppression 
    • Chemotherapy 

     

    Investigations relevant to consultations to this Specialty 
    • Cross sectional imaging 
    • ERCP/MRCP 
    • Bloods (including tumour markers) 

     

    Essential Investigations required for specific consults 
    • LFTs AND INR (for liver problems) 
    • Tumour markers (for cancers) 
    • 3 phase CT may be appropriate (ask) 

     

    Investigations relevant to consultations to this Specialty 
    • 3 phase CT 
    • Tumour markers 
    • LFTs and INR 
    • Hepatitis screen (HBVSAg, HCV Ab) 

     

    Common problems in calls for consults 
    • We’re approachable (generally), provided you have a good story to tell 
    • Please see patients before consulting us 

     

    Urology

    Common questions/reasons for consults to this Specialty 
    • Renal Colic 
    • Haematuria 
    • Fournier’s gangrene 
    • Scrotal Pain 

     

    General clinical information/questions relevant to consults to this Specialty 
    Essential 
    • History and examination findings 
    • Haematuria 
    • Lower urinary tract symptoms 
    • Renal function 
    • Comorbidities 
    • Presence of sepsis 

     

    Helpful 
    • CT KUB 
    • Urinary MCS, cytology 

     

    Common question-specific information required 
    • Renal stone: size, location, symptoms, 
    • Renal function, 
    • Presence of sepsis 
    • Haematuria – clots, retention, colour; history of benign prostatic hyperplasia, cancer, radiation, anticoagulants 
    • Fournier’s – immunocompromised, DM, alcohol, obesity, known genitourinary/GIT pathology, tenderness, crepitus, numbness 
    • Scrotal pain – age, history, previous pain, urinary symptoms, sexual history 

     

    Background Medical History relevant to consults to this Specialty 
    (E.g. previous contact with Specialty, letters, reports, o/s travel, etc.) 

    Previous letters and reports are important

     

    Medications relevant to consultations to this Specialty 
    • Anticoagulants 
    • Antiplatelet medications 
    • Immunosuppression 
    • Steroids 
    • Nephrotoxic medications 

     

    Investigations relevant to consultations to this Specialty 
    • MSU 
    • Urine cytology 
    • CTKUB or CT 3 phase 
    • Renal function 

     

    Essential Investigations required for specific consults 
    • Haematuria – MSU, Upper tract imaging, cytology 
    • Stones – CTKUB, Renal function, Urinalysis/MSU 
    • Fournier’s - FBC,CRP,coagulation studies +/- CT if in doubt 

     

    Investigations relevant to consultations to this Specialty 
    • Renal function 
    • MSU 
    • CT 

     

    Vascular Surgery

    Common questions/reasons for consults to this Specialty 
    • Leg ulcers 
    • Fistula problems 
    • Vascular trauma 
    • Peripheral arterial disease 
    • Carotid disease 
    • Abdominal aortic aneurysms 
    • Placement Hickman 
    • FMETe aneurysm/haematoma post arterial puncture 

     

    General clinical information/questions relevant to consults to this Specialty 
    Essential 
    • Duration symptoms 
    • Previous interventions 
    • Is limb/life at immediate risk 

     

    Helpful 
    • Presentation acute or chronic 

     

    Background Medical History relevant to consults to this Specialty 
    (E.g. previous contact with specialty, letters, reports, o/s travel, etc.)
    Essential 
    • Diabetes 
    • Renal Function 
    • Hypertension 
    • IHD 
    • Hypercholesterolaemia 

     

    Helpful 
    • Previous arterial interventions (open and endovascular) 
    • Previous contrast reaction 

     

    Family/social history relevant to consults to this Specialty 
    Essential 
    • Smoking status 
    • General pre-morbid function – mobility, at home, or in care 
    • Familial history of vascular disease 

     

    Medications relevant to consultations to this Specialty 
    • Warfarin/heparin/novel anticoagulation 
    • Anti-platelets 
    • Metformin 

     

    Investigations relevant to consultations to this Specialty 
    • Renal function 
    • Coagulation studies 
    • Ankle brachial pressure indices/toe pressures
    • Previous cardiovascular imaging 

     

    Essential Investigations required for specific consults 
    • Investigations will be directed by the vascular team as appropriate for the presenting problem 

     

    Investigations relevant to consultations to this Specialty (and why) 
    • DSA (best way of visualising crural vessels) 
    • CTA (non-invasive but may use more contrast than angiography) 
    • Ultrasound (especially for fistulae or fMETe aneurysms) - non-invasive and provides information on flow as well as anatomy 

     

    Extra tips for acquiring consults 
    • For peripheral arterial disease check pulses proximally (femoral pulses are often not examined)
    • If you think the patient may need an urgent procedure, please keep the patient Nil By Mouth 

     

     

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