Committed to Research

Overview

You've been asked to arrange a consult, but who do you ring and what will they insist on knowing?

The guideline below gives handy tips for each specialty. Just click on the department you are interested in. 
Some universal advice includes:
  • Get in early - no registrar will thank you for a new consult at 4:30 in the afternoon
  • Formulate your question in advance - what question do you need answering? If unsure check with your registrar
  • Know your patient - don't ring up without knowing the important details of their history and without having examined them
  • Remember ISBAR - & get the important information out early
  • Anticipate what the team being consulted will want to know - and that's why the guidelines below exist

Anaesthesia

1. Mechanism for requesting a consult
  • Contact the anaesthetist in charge on pager 8460
  • State your name and position
  • State reasons for consult
  • Specify what procedure and when it is scheduled for
    •  

      2.Common reasons for consults:
      • Review prior to surgery or procedures requiring anaesthetic support
      • Assistance with intravenous access

       

      3. Please state significant comorbidities particularly cardiovascular, respiratory, musculoskeletal, airway issues
      • Include results of investigations appropriate to disease
      • Be able to answer these 2 questions: can patient lie flat? Can patient walk up 2 flights of stairs?

       

      4. Submit a consult form to the Anaesthetic Department after contacting 8460.
      Include clinical details of patient as well as name of person obtaining consult and contact details in the form.

      Note:
      • Please keep the phone conversation with 8460 brief and to the point
      • We will only review patients without an anticipated operation/procedure date in exceptional circumstances
      • Please be legible and do not use abbreviations 

Bone Marrow Transplant

1. Common questions/reasons for consults to this Specialty
  • Malignant haematological disease requiring curative treatment
  • Fever
  • Diarrhoea

 

2. General clinical information/questions relevant to consults to this Specialty Essential
  • What is the underlying disease
  • Date of transplant
  • Was the transplant from themselves (autologous) or from another person (allogeneic)
  • What drugs were given (conditioning) just prior to the transplant

 

3. Common question-specific information required
  • How high has the fever been in the last 24 hours
  • Is fever associated with rigor/chills or hypotension
  • How many times has diarrhoea occurred over the last 24 hours
  • Is there associated abdominal pain or cramping

 

4. Family/social history relevant to consults to this Specialty Essential
  • Is the patient married and does he/she have children and if so what ages? Have they seen the patient within the last few days?

 

5. Medications relevant to consultations to this Specialty
  • Prednisone
  • Cyclosporine or tacrolimus
  • Mycophenolate
  • Any antibiotics

 

6. Investigations relevant to consultations to this Specialty
  • Last (today’s) full blood count
  • Biochemistry and liver function tests
  • Most recent cyclosporine/tacrolimus level in blood
  • CXR
  • Any recent positive blood cultures, stool or urine cultures

Breast Surgery


1. Mechanism for requesting a consult
Page # 9567 (the team registrar) if urgent consult required for inpatient If consult required on an outpatient basis- i.e. to be seen in clinic- complete a referral form and fax to 9845 8334 (Breast Cancer Institute)

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

 

2. 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 (ie 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
  • Systemic symptoms (fever, nausea, weight loss etc)
  • Medical/Surgical history
  • Medications
  • Pregnancy history

 

3. 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
  • 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

 

4. 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

 

5. 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

 

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

 

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

 

8. Essential Investigations required for specific consults
Breast Lump/Lesion
  • Mammogram
  • Breast Ultrasound
Breast Abscess:
  • FBC
  • Previous culture results (if available)
  • Breast ultrasound

 

9. 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.

 

Dec 2016

 

Cardiology

1. Mechanism for Requesting 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

     

    Cardiothoracic Surgery

    1. Mechanism for requesting a consult
    Page # 22828 – for all Cardiothoracic issues in and out of hours
    (held by consult Reg/SRMO in hours and Cardiothoracic ICU reg out of hours) 

    2. Common questions/reasons for consults to this Specialty
    • Pre-operative assessment for coronary arteries or valve surgery;
    • Chest trauma (blunt and penetrating);
    • Insertion and management of chest drains;
    • Management of pleural effusion (malignant and parapneumonic);
    • Pre-operative assessment for Pacemaker and AICD insertion;

     

    3. General clinical information/questions relevant to consults to this Specialty
    Essential
    • Personal details of the patient including current clinical haemodynamic status (stable or unstable)
    • Reason for consultation
    • Signs and symptoms
    • Previous medical history (detailed)
    • Relevant comorbidities
    • Imaging already performed
    • Anti-platelet medications/anti-coagulation if on board
    • Mobility status
    Helpful
    • Public/Private insurance (for logistical reasons)
    • Allergies

     

    4. Common question-specific information required
    • Symptoms of ischemic heart disease or heart failure
    • Acute or elective presentation
    • Angiogram/echo/CXR/carotid ultrasound
    • CXR/CT results (thoracic consult)
    • Bloods abnormalities: FBC and coagulation studies
    • Renal and hepatic function: EUC, LFT
    • Respiratory function: spirometry
    • Blood culture and septic status if infective endocarditis or empyema
    • Mobility status
    • For trauma call standard ABCD (ATLS assessment)
    • Serology

     

    5. Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc) Essential
    • HTN,DM, hypercholesterolaemia, family history, obesity, smoking history
    • Previous coronary of valve intervention (surgical or cardiac catheter lab)
    • Previous heart surgery
    • IVDU if infective endocarditis
    • History of previous cerebrovascular events
    • History of peripheral vascular disease
    • History of renal or hepatic failure
    • History of respiratory failure especially if home oxygen required
    • Any previous history of coagulopathy (bleeding or pro-thrombotic)
    Helpful
  • Allergies
  •  

    6. Family/social history relevant to consults to this Specialty Essential
    • Family history of CAD or lung cancer
    • Smoker status
    • Alcohol consumption
    • IV drug use
    • Social situation (where the patient lives and with whom)

     

    7. Medications relevant to consultations to this Specialty
    • Anti-platelet medications of any sort
    • Anti-coagulants of any sort
    • Beta-blockers
    • Insulin or oral glycaemic control
    • Current antibiotic therapy
    • Inotropes if patient unstable (CCU or ICU)
    • Immunosuppression
    • Steroids

     

    8. Investigations relevant to consultations to this Specialty
    • Angiogram
    • Echo
    • CXR
    • ECG
    • Carotid Duplex US
    • CT chest
    • Spirometry

     

    9. Essential Investigations required for specific consults
    • Any pre-op consult for cardiac surgery: CXR, coronary angiogram, echo, Spirometry, FBC, EUC, LFT, Coagulation studies, Group & Save, Hepatitis and HIV serology
    • If history of previous CVA or Left Main disease: carotid duplex US
    • If Aortic surgery: CT aortogram
    • For thoracic surgery: CXR, CT chest, Bloods, Spirometry
    • For chest trauma: CXR and CT chest
    • For Pacemaker/AICD: ECG, CXR

       

    10. Investigations relevant to consultations to this Specialty (and why)
    • If history of previous CVA or Left Main disease: carotid duplex US (there is a strong association for concomitant CAD and carotid stenosis)
    • All other investigations are essential

     

    11. Extra tips for acquiring consults
    Strongly recommend use of a Consult Sheet to place at the top of the patient notes with a summary of patient presentation, history and reason for consultation. It makes it easier for the Cardiothoracic Surgery team to access all the relevant information without the need of reviewing all the patient

     

    Colorectal Surgery

    1. Requesting a consult
    Page the colorectal consults number 9687

     

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

     

    3. 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)

     

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

     

    5. 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?)

     

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

     

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

     

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

     

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

     

    Dec 2016

     

    Dental Health – Emergency and General Practice Dentistry


    1. Common questions/reasons for consults to this Specialty
    o Dental Review Prior to Major Surgeries
    o To address pain of dental origin for inpatients
    o Dental review prior to commencement of bisphosphonates
    o Denture Issues for inpatients
    o To rule out source of infection of dental origin
    o Review of Dental trauma during intubation for GA

     

    2. General clinical information/questions relevant to consults to this Specialty
    o Essential
    • Medical history
    • Radiographic examination
    • If the patient can be transported to WCOH
    • Medication
    • If patient has MRO infection
    o Helpful
    • History of complaint
    • Proposed treatment (if any – e.g. valve replacement etc)
    • Discharge schedule
    • Centerlink eligibility
    • If self-consenting or under guardianship
    • If nurse escort is required

    3. Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc)
    o Essential
    Need for antibiotic prophylaxis
  • Use of anticoagulants
  • MRO infection
  • Allergies and Drug interactions
  • o Helpful
    • Blood cell count and coagulation studies
    • Liver function tests when applicable

     

    4. Medications relevant to consultations to this Specialty
    o Anticoagulants
    o Medications used for osteoporosis such Bisphophosphonates, Denosumab

     

    5. Investigations relevant to consultations to this Specialty
    o Radiographs mainly OPG
    o Blood tests as above

     

    6. Common problems in calls for consults
    o Inadequate time for dental review
    o Centrelink eligibility
    o Occasionally missing patient details (name, contact details)
    o Contact details of referring clinician not always available

     

    Dermatology


    1. Mechanism for requesting a consult
    • For inpatients - page 27349 in hours or the on call registrar via mobile after hours (contact through switch)
    • For outpatients fax referral to (02) 8890-9673
    • If urgent outpatient appointment needed discuss with Derm Reg on Call
    • Dermatology provides a consulting service – it is not possible to request ‘biopsy only’

    2. Common questions/reasons for consults to this Specialty
    • Any “rash”, exanthema, dermatitis
    • Cutaneous Infections
    • Drug reactions, eczema, urticaria, etc.
    • Skin Cancer o Blisters on the skin, suspected SJS/TEN

    3. General clinical information/questions relevant to consults to this Specialty
    Essential
    • Good history of the “rash” (timing, evolution)
    • For any rashes: Medication history, timing important (when medications commenced and ceased)  - best done by chart
    • Past medical history
    • Description (as accurate as possible) - www.dermnetnz.org/topics/terminology
    Helpful
    Photography (referrer should obtain patient’s consent, and images sent through private/secure channels. Once a proper WSLHD system is established, this will be essential)

     

    4. Common question-specific information required
    • Detailed description of timing and evolution of eruption
    • Investigation findings where relevant (swabs, fungal scrapings, FBC, eosinophil count etc)
    • Detailed medication history where relevant

     

    5. Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc)
    Essential
    • For “rashes”, possible drug reactions: medication history (with start and end dates)
    • Any history of skin changes, dermatological history (atopy, psoriasis)

    6. Family/social history relevant to consults to this Specialty
    • Family history of similar conditions or common dermatological conditions: psoriasis , atopy

     

    7. Medications
    • All systemic medications
    • Names of topical medications

     

    8. Investigations relevant to consultations to this Specialty 
    • For rashes: any laboratory data


    9. Investigations relevant to consultations to this Specialty (and why)
    • Biopsy: helpful for some “rashes” and skin cancer. Guided by clinical manifestations. We do not usually want other teams to biopsy skin lesions as lesion selection is critical.
    • For possible autoimmune diseases, vasculitis: autoimmune panel, ANCA, etc.

     

    10. Common problems in calls for consults
    • Almost no clinical information provided (“skin rash”, “for evaluation”)
    • Very late referrals, when lesions have evolved and are not very relevant. We prefer to see patients as early as possible.
    • Consults “for biopsy”. We use biopsies quite often, but biopsies are rarely diagnostic in inflammatory conditions, and there should be always a clinic-pathological correlation. We prefer to be consulted and we will decide about biopsies

    Nov 2017

    Diabetes Management

    1.Mechanism for requesting a consult
    • Patient known to consultant: refer to team registrar
    • New patient:
      • Refer to on call registrar
      • Surgical diabetes: refer to pg 8932

    2. Common questions/reasons for consults to this Specialty
    • Poorly controlled diabetes
    • Steroid induced hyperglycaemia
    • Recurrent hypoglycaemia

    3. General clinical information/questions relevant to consults to this Specialty
    • Essential
      • Type 1 vs Type 2
      • AC & PC BSL
      • HbA1c – add-on to admission blood
      • Medications – DM
      • Medications – Steroids – Dose and weaning plan
      • Weight
      • Diet/Enteric Feeds/TPN -> rates/ proposed rate change
    • Helpful
      • D/C plan/prognosis (include time for adequate discharge)
      • Social situation – ability to self-inject

    4. Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc)
    • Essential
      • Known to (which specialist)
      • Past history of pancreatitis, cirrhosis, CKD
    • Helpful
      • Creatinine

    5. Family/social history relevant to consults to this Specialty
    • Essential
      • Cognitive impairment/carer
      • Ability to test BSL/ inject insulin

    6. Medications relevant to consultations to this Specialty
    • Steroids and indication and weaning

    7. Investigations relevant to consultations to this Specialty
    • HbA1c
    • Fasting glucose
    • C peptide if possible pancreatic insufficiency

    8. Common problems in calls for consults
    • Calling to request a consult on the day of/day before discharge

    9. Extra tips for acquiring consults Please note the registrar is in clinic for ½ the day, most days; the diabetes educators are seeing dozens of patients per week and d/c planning cannot occur instantaneously! Consult early in the admission.

    Dec 2016

    Ear, Nose & Throat Surgery

    1. Mechanism for requesting a consult 
  • During work hours: page oncall pager #22691
  • Afterhours: through switch to oncall registrar’s mobile

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

    3. General clinical information/questions relevant to consults to this Specialty History
    • Epistaxis: anterior/posterior bleed, blood pressure, anticoagulants, treatment trialled
    • 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), mastoid swelling/tenderness/erythema
    • Post-tonsillectomy bleed: oral cavity (bleeding point, active bleeding/clot visible)

    4. 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, previous tonsillectomy
    • Ear pain: Recent URTI, recent water exposure/trauma, immunocompromise

    5. Family/social history relevant to consults to this Specialty
    • Smoking history
    • Alcohol history

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

  • 7. 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

    8. 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 + venogram (mastoiditis)
    • CT Paranasal Sinuses
    • CT Neck with contrast
    • US Neck (salivary gland infection/collection)

    9. 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
    • Neck: masses, tenderness

    10. 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.


  • Nov 2017

     

    Endocrinology

    1. Mechanism for requesting a consult
    • Patient known to consultant: contact team registrar
    • New patients: contact endocrine registrar on call
    • Surgical diabetes: contact surgical diabetes registrar pg 8932

    2. Common questions/reasons for consults to this Specialty
    • Management of hyperglycaemia
    • Hyponatraemia
    • Abnormal TFTs
    • Hypercalcaemia

    3. General clinical information/questions relevant to consults to this Specialty
    Essential
    • Relevant imaging and biochemistry
    • If known to an Endocrinologist

    4. Common question-specific information required 
    Diabetes
    • Type 1 vs type 2 diabetes vs other cause of diabetes (eg pancreatitits)
    • HbA1c result
    • Blood glucose readings (ideally ac/pc)
    • Medications
    • Feeding status (eg TPN, enteric feeds, NBM)
    • Creatinine
    • Discharge plan
    • Social situation
    • Weight
    Hyponatraemia
    • Serum osmolality, potassium
    • Urine sodium/osmolality
    • Baseline sodium
    • Medication, esp diuretics
    • Fluid status
    • If Cr > 150, consults refer to renal team

    5. Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc)
    Essential
    • Known to any Endocrinologist?

    6. Family/social history relevant to consults to this Specialty
    Essential
    • Self-care ability, home support

    7. Medications relevant to consultations to this Specialty
    • Diabetes medication
    • Steroids

    8. Investigations relevant to consults to this Specialty
    • HbA1c
    • Fingerprick BGs
    • creatinine

    9. Essential Investigations required for specific consults
    Essential
    • Diabetes: HbA1c, creatinine, weight
    • Hyponatraemia: serum Na, K, creatinine, serum osmolality, urine Na, urine osmolality (helpful: TFTs, morning cortisol)

    10. Extra tips for acquiring consults 
    For diabetes consults do not wait until day of discharge
    Note that the Endocrine Registrars spend ½ days in clinic every day. Placing consults early in the day is appreciated.

     

    Dec 2016

    Gastroenterology & Hepatology

    1. Mechanism for requesting a consult
    The consult pager is #8651 for all consults, including PEGs during working hours. For all ED referrals the page is #9413. Both of these pagers are carried by advanced trainees.

     

    2. Common questions/reasons for consults to this Specialty
    • GI Bleeding (incl. iron deficiency anaemia)
    • Abnormal LFTs (including treatment of viral hepatitis)
    • Diarrhoea
    • PEG insertion
    • Management of liver cirrhosis
    Please note that undifferentiated abdominal pain should be referred to the surgical team (ASU) in the first instance.

     

    3. General clinical information/questions relevant to consults to this Specialty
    Essential
    • GI symptoms: abdominal pain, jaundice, nausea/vomiting, bowel habits (in comparison to baseline)
    • Past Medical History
    • Current medications (including OTC & herbals)
    • Haemodynamic parameters
    • Blood results (HGB, MCV, PLT, Coagulation studies, EUC, LFT; additionally iron studies/Vit B12/folate if consult is for anaemia)
    Helpful
    • Previous related investigations incl. endoscopies
    • Imaging (eg US or CT)

     

    4. Common question-specific information required
    • GI bleeding: Be very clear regarding melaena vs haematochezia (black vs dark red/red), haematemesis, use of NSAIDs/anticoagulants, haemodynamics + fluids given. The referring doctor should have viewed stool samples themselves or have performed a PR examination (stool chart or nursing documentation is insufficient). Previous related investigations incl. endoscopy reports have to be chased by the admitting team. Please call early to expedite endoscopic procedures.
    • Abnormal LFTs: medication (please attempt to clarify their most recent and up to date medication summary), alcohol and IVDU histories, fever, clinical features of chronic liver disease (ascites, jaundice, encephalopathy/asterixis.
    • If the question is regarding viral hepatitis such as Hep C or Hep B please clarify what treatment they have had and when this was started.
    • Diarrhoea: bowel symptoms as compared with baseline (frequency, consistency, colour, duration), constitutional symptoms, travel history.
    • PEG insertion: Essential are the precise reason for PEG insertion (irreversible dysphagia in an appropriate patient, Head & Neck malignancy, etc)and the related prognosis of the patient (short and long term). Relevant past history (respiratory failure, concomitant dementia, neurological condition). Speech pathology assessment, consent issues (family, guardianship), weight loss.

     

    5. Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc)
    • Letters from treating gastroenterology specialist
    • Previous endoscopic investigations, CT or MRI.
    • Travel history
    • Surgical history
    • Malnutrition

     

    6. Family/social history relevant to consults to this Specialty,
    Essentia
    • lEtOH use & IVDU
    • Family history GI malignancies (HCC/CRC/gastric cancer)
    Helpful
  • Home situation (long term treatment/transplant)
  • Social Supports
  •  

    7. Medications relevant to consultations to this Specialty
    • NSAIDs
    • Paracetamol
    • Antibiotics
    • Anticoagulants
    • Herbal remedies and food supplements

     

    8. Investigations relevant to consultations to this Specialty
    • FBC/LFT/EUC/viral serology/Fe studies
    • Abdominal imaging (esp US/CT/MRI+MRCP)
    • Endoscopic investigations
    • Previous blood tests for comparison

     

    9. Essential Investigations required for specific consults
    • GI bleeding: FBC, EUC, LFTs, Coagulation studies, iron studies
    • Abnormal LFTs: FBC, EUC, LFTs, Coagulation studies, iron studies inflammatory markers, viral serologies (HBV & HCV), abdominal US
    • Diarrhoea: eosinophil count, inflammatory markers, stool investigations (MCS, OCP, C. difficile, +/- viral antigens, i.e. norovirus, rotavirus, adenovirus),
    • PEG: speech path assessment +/- barium swallow/MBS

     

    10. Investigations relevant to consultations to this Specialty (and why)
    • Abdominal US: liver size/contour, signs of portal HT, portal and hepatic diameter and vein flow, ascites
    • MRI liver/MRCP: diagnosis of biliary abnormalities/pancreatitis, liver lesions
    • Recent endoscopic investigations – to get an idea of what has been treated previously.

     

    11. Common problems in calls for consults
    • Refer as early as possible.
    • Not enough information for consult reason (please clarify with your senior team members the reasons for you consult)
    • If you suspect GI bleeding, keep NBM.

     

    12. Extra tips for acquiring consults
    Be very clear about the reason for the consult, i.e. have a specific question you (or your team) want answered.

     

    Dec 2016

     

    Genetic Medicine


    1. Mechanism for requesting a Consult
    Page # 84812.

    2. Common questions/reasons for consults to this Specialty
    o Metabolic disorder/inborn-error of metabolism
    o For consideration of genetic testing for specific disorders
    o For consideration of possible genetic disorder (i.e. characteristic features or strong family history of disorder)
    o NICU – dysmorphic features/concern for diagnosis of genetic syndrome/chromosomal abnormality

    3. General clinical information/questions relevant to consults to this Specialty
    o Essential
    • What is the reason for the consult?
    • Summary of the clinical history
    • If for consideration of specific genetic testing – which tests/group of tests are you requesting; what is the urgency for the testing; what is the reason for the testing (ie diagnosis/guide management/family planning)
    • Family history
    • Make sure the patient and family know that genetics have been consulted and the reason why
    o Helpful • Letters/info from reviews by other teams/clinicians
    • Childhood history (intellectual disability, health problems)
    • Results of previous genetic/diagnostic testing

    4. Common question-specific information required
    NICU – maternal history, including any testing done during pregnancy (nuchal/CVS/amnio; morphology scans; consanguinity; screening of other affected relatives)

    5. Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc)
    o Essential
    • Letters/info from reviews by other teams/clinicians
    • Results of previous genetic testing (chromosomes or specific genes)

    6. Family/social history relevant to consults to this Specialty
    o Essential
    • Detailed family history, including if genetic testing performed in other family members
    • Consanguinity
    • Ethnicity (helpful but not essential)

    7. Medications relevant to consultations to this Specialty
    o All!
    o Diet

    8. Investigations relevant to consultations to this Specialty
    o Previous genetic testing
    o Relevant imaging

    9. Essential Investigations required for specific consults
    Marfans Syndrome/?Connective Tissue Disorder – echocardiogram, eye review

    10. Investigations relevant to consultations to this Specialty (and why)
    o Chromosome microarray (in dysmorphic neonate or adult with intellectual disability)
    o Storage of DNA – send 10ml EDTA blood to Molecular Genetics at Children’s Hospital Westmead (we will request this if we are considering ordering a genetic test)
    o Urine metabolic screen – send spot urine to biochemical genetics at Children’s Hospital Westmead (we will request this for some metabolic disorders)
    o Plasma Amino Acids –plasma to biochemical genetics at Childrens Hospital Westmead, urgent send-away (requested for monitoring and diagnostic purposes)
    o Acylcarnitine Profile - plasma to biochemical genetics at Children’s Hospital Westmead, urgent send-away (requested for monitoring and diagnostic purposes)

    11. Common problems in calls for consults
    o Most common issues centre around the reason for the consult. If you are requesting a consult for diagnosis of a genetic condition or for testing for a genetic condition, it is very helpful to know which condition or group of conditions your consultant is considering and why.
    o Patient/parents should always be advised that a genetic consult has been requested and why.
    o For NICU patients – if you are ordering a chromosomal microarray prior to our consult, please ensure that the parents are appropriately informed about the possibility of incidental findings and variants of unknown significance.

    12. Extra tips for acquiring consults
    There is a separate service for Cancer Genetics – contact via switch or located at cancer care centre (Familial Cancer). Page on-call Genetics Fellow for all consults.

    Geriatric Medicine


    1. Mechanism for requesting a consult
    o Rehab Consults – Contact geriatrics rehab advanced trainee (non-surgical patients). Contact surgical liaison geriatrics advanced trainee for surgical patients.
    o General Geriatrics Consults – Contact geriatrics rehab advanced trainee
    o Psychogeriatrics Consults – Contact psychogeriatrics advanced trainee if admitted under geriatrician, otherwise contact CL psychiatry if admitted in other teams
    o ED Admissions Consults – Contact consultant on call, or HOPE ED reg for review

     

    2. Common questions/reasons for consults to this Specialty
    o Rehabilitation
    o Transfer of care (from surgical team and complex medical issues)
    o Cognition
    o Discharge planning
    o Delirium Management
    o Dementia assessment

     

    3. General clinical information/questions relevant to consults to this Specialty
    o Essential
    • Current medical and functional status and current medications
    • Previous level of functioning (PT, OT, cognition) and Current level of functioning (PT, OT, cognition)
    • Mobility/Toileting/Showering/Feeding
    • Home/Family situation
    • Allied Health Reviewed [Physiotherapy, O.T, S.W input]
    • Cognition assessment (MMSE/RUDAS)
    • Advanced Care directive
    • Comorbidities
    • Delirium/Dementia work up if done
    • Last geriatric admission
    o Helpful
    • Social support
    • Previous ACAT assessments
    • Behavioural issues
    • Osteoporosis work up (Vitamin D)
    • Dementia screen [TFT, Vitamin B12, Folate]

     

    4. Common question-specific information required
    o Onset of symptoms
    o Investigations
    o Behavioural chart
    o Patient and family expectations

     

    5. Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc)
    o Essential
    • Previous contact and speciality
    • Previous cognitive assessment
    • Outpatient visit [Geriatrician]
    • Last MMSE
    • Advanced Care Plan
    • Previous discharge summaries

     

    6. Family/social history relevant to consults to this Specialty
    o Essential
    • Social support
    • Services
    • Next of kin
    • Premorbid function and services
    o Helpful
    TOP 5 for Delirium Management

     

    7. Medications relevant to consultations to this Specialty
    o All medications [please check with GP/Family]
    o Psychotropic medications,
    o How medications are administered (e.g. webster pack)

     

    8. Investigations relevant to consultations to this Specialty
    o Dementia screen (cerebral imaging - CT or MRI)
    o Septic screen (blood culture, CXR, urine mcs)
    o Vitamin D
    o Vitamin B12 and Folate
    o TFT

     

    9. Essential Investigations required for specific consults
    o Cognition: TFT, VitB12 and Folate, cerebral imaging
    o Delirium: septic screen, EUC, FBC, LFTs, C/M/P, TFT, cerebral imaging
    o Osteoporosis: Vitamin D, any previous BMDs
    o Dementia: Vitamin B12 folate, TFTs, cerebral imaging

     

    10. Investigations relevant to consultations to this Specialty (and why)
    o As above for delirium and dementia screening, bone health
    o Vitamin D

     

    11. Common problems in calls for consults
    o Inadequate allied health information
    o Inadequate knowledge of premorbid functioning or current functional status
    o Inadequate knowledge of family situation or expectations

     

    12. Extra tips for acquiring consults
    We prefer consults for addressing a specific question rather than to conduct a “general geriatric review” or to take over care. Allied health input is essential prior to any possible rehab consults.

     

    Jun 2017

    Haematology

    1. Mechanism for obtaining a consult in this speciality

    Consult pager 22926 (thrombosis, haemostasis and obstetric)
    • DVT
    • Unexpected / abnormal coagulation study results
    • Suspicion of HIT (heparin induced thrombocytopenia)
    • Thrombocytopenia in pregnancy, and other haematologic disorders during pregnancy
    Consult pager: 8685 (general and malignant)
    • Unexpected / abnormal FBC results
    • Possibility of haematologic malignancy, or advice on the assessment of one
    • Any other question not covered by the other registrar services.
    Transfusion pager 27150 (and 24-hour transfusion mobile phone: 0409 392 151)
    • Advice on interpretation of unexpected abnormal results (FBC and coagulation studies) that may require transfusion or reversal of anticoagulants
    • Assistance during “massive transfusion protocols” (MTP)
    • If you have activated an MTP the blood bank will inform this registrar
    • Provision of advice on bleeding patients who are anticoagulated
    • For discussion of transfusion requests that are contrary to the National Blood Authority Guidelines (the blood bank will not issue blood products without prior discussion with this registrar if your request does not meed NBA guidelines).

    • Carried by the laboratory registrars (a ‘physical consult’ will not occur when discussing cases with these registrars)

    2. Common questions/reasons for consults to this Specialty
    • Transfusion requests
    • Cytopenias (Thrombocytopenia / Anaemia / Neutropenia)
    • DVT
    • Haematological malignancy

    3. General information/questions relevant to consults to this Specialty

    Transfusion requests
    • Red blood cells, platelets, fresh frozen plasma, cryoprecipitate and prothrombinex are the most common products requested.
    • You should know the indication for transfusion along with the current Hb, platelet count, PT / APTT / INR, it may also be useful to know the blood group, fibrinogen and patient weight and creatinine in certain circumstances.
    • Common indications for transfusion are:
      • Moderate anaemia (Hb 70 – 90 g/L) with additional co-morbidities 
      • Acute bleeding (a fibrinogen is very useful in these cases)
      • Reversal of warfarin (patient weight is required)
      • Bleeding or emergent surgery in a patient on a “NOAC” (weight, creatinine and time of last dose are required)
    • Is there a recent group and screen?

    Cytopenias
    • The causes are generally divided into failure of production (e.g. a primary or secondary bone marrow failure) or increased loss or destruction (bleeding, haemolysis, drug and immune mediated causes as well as infection/inflammatory states).
    • It is useful to have previous test results, as well as a medication / drug history to go with the recent clinical course of the patient.
    • The three main life-threatening conditions associated with thrombocytopenia are TTP/HUS, HIT and DIC
      • TTP / HUS: perform an urgent haemolytic screen if this is suspected and review the blood film comment.
      • HIT: heparin exposure over the last 3 months needs to be established. 
      • A “4 T score” should be evaluated. (UpToDate has a calculator)
      • DIC: arises as a result of a severe physiological insult, assess FBC, PT / APTT, fibrinogen, thrombin time, D-dimer and review the blood film comment.


    DVT
    • Where is DVT? Is it acute or chronic?
    • Provoked or unprovoked?
    • 1st or recurrent episodes?
    • Any evidence clinically of autoimmune disease (e.g. lupus) or miscarriages – suggests possible antiphospholipid antibody syndrome
    • Any symptoms or signs to suggest malignancy (especially smokers and patients with associated unexplained anaemias in association with DVT)
    • Prior to treatment
      • BetaHCG in women of child bearing potential
      • Baseline FBC, PT / APTT, Creatinine and liver function tests
      • Presence of contraindications to anticoagulation, or bleeding risk factors

    Haematological malignancy
    • Core and excision biopsies are required. Fine needle aspirates are inadequate for diagnosis of haematologic malignancies.
    • If doing a biopsy, please send a FRESH sample for flow cytometry AND FORMALIN FIXED sample for histopathology. 
      • If there is enough tissue, a FRESH sample for cytogenetics is also useful.


    4. Medications relevant to consultations to this Specialty
    • Heparin, clexane (dose and when started)
    • Warfarin (recent INR)
    • NOACS”: 
      • Dabigatran (brand name Pradaxa), Rivaroxaban (Xarelto), Apixaban (Eliquis)

    5. Investigations relevant to consultations to this Specialty
    • FBC and blood film (“scientific review” and/or “haematology consult” underneath the FBC), Iron studies, B12/folate studies, Coagulation studies, Creatinine and patients weight
    • Previous biopsy results (including bone marrows)


    6. Investigations relevant to consultations to this Specialty
    Mixing studies 
  • Help differentiate between factor deficiency and factor inhibitor as cause for prolonged PT / APTT
  • Thrombin time / fibrinogen 
  • Help refine the cause of an unexplained prolongation of PT / APTT by determining if there are additional abnormalities in the coagulation pathways
  • “Haemolytic screen” 
  • DAT, LDH, reticulocyte count, haptoglobin and (indirect) bilirubin
  • Anticoagulant drug-specific levels
  • Can be used to monitor: 
    • Heparin, clexane, apixaban, rivaroxaban and dabigatran
  • Each test is specific to the drug in use, the laboratory must be informed which drug is being used for the result to be meaningful


  • 7. Extra tips about haematology consults 
    The National Blood Authority guidelines advise on best practice of blood transfusion (https://www.blood.gov.au/pbm-guidelines)
    • When calling the Westmead blood bank, if your request does not meet the guideline standards you will be asked to contact the transfusion / laboratory haematology registrar. This does not mean your request will be denied, but the case must be discussed prior to transfusion.

    All requests for FFP, platelets, prothrombinex and idarucizumab (dabigatran antidote) to the blood bank will be referred to the transfusion / laboratory registrar.

    8. Which consultant to call (and other hospitals in the network)
    Bone marrow transplant patients
  • If the patient has undergone an allogeneic bone marrow transplant, they will always be cared for by the bone marrow transplant service. There is a bone marrow transplant specialist oncall all week, they are the specialist to contact for this patient 24 hours a day.
  • After-hours shifts and admitted patients
    • If there is uncertainty on how to proceed with medical care, or there is significant deterioration in the patient’s condition the attending specialist can always be called.
    • If the specialist cannot be reached, but their phone has rung, you should leave a message so they can call back. If they do not return your call, then the oncall haematologist can be contacted.
    • Calling from other hospitals (Auburn, Blacktown, Mt Druitt)
      • In regular working hours (8am – 430pm), Blacktown/Mt Druitt has a consult service (via the haematology / oncology BPT – pager 7600) and the haematologists at Blacktown
      • Out of regular hours, the Westmead haematologist oncall is the specialist to contact.
      • At Auburn, all haematology consults are directed to the Westmead haematologist oncall at all times.

      • The exception to the rules above for Auburn and Blacktown are for transfusion and laboratory advice: contact the transfusion / laboratory haematology registrar Pager 27150 (and 24-hour transfusion mobile phone: 0409 392 151)

      Feb 2018

    Head and Neck Cancer Clinic Dental Service

    1. Common questions/reasons for consults to this Specialty
    Dental Consultation prior to Head and Neck chemoradiotherapy- Crown Princess Mary Cancer Care Multidisciplinary Head and Neck Clinic patients

     

    2. General clinical information/questions relevant to consults to this Specialty
    o OPG radiograph
    o Chemo/Rad/Surgical treatment plan including fields and dates of commencement, simulation and PET.
    Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc)
    Full medical history required

     

    3. Medications relevant to consultations to this Specialty
    All medications prescription and non-prescription

     

    4. Investigations relevant to consultations to this Specialty
    o PET,
    o Radiographic studies
    o CT,
    o Histology including sentinel node biopsy,
    o Staging of disease

     

    5. Investigations relevant to consultations to this Specialty
    o OPG,
    o Small film dental radiographs,
    o Cone beam CT

     

    6. Common problems in calls for consults
    Referral is done internal to the multidisciplinary clinic so tends to only be from Senior Registrars and Consultants within the team (JMO’s are not usually involved in the referral of these patients to the service)

     

    Head and Neck Surgical Oncology

    1. Mechanism for requesting a consult

    • Page #9453
    • Call mobile through switch - either head & neck reg or Surgical Oncology reg (2 STE regs in the team)

     

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

     

    3. General clinical information/questions relevant to consults to this Specialty
    o 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 eg within 1 week (Burkett’s lymphoma), within 1 month (low grade lymphoma). Ask the consultant in charge prior to calling
    o Thyroid nodule
    • Symptoms
    Hyperthyroidism/hypothyroidism
  • Obstructive symptoms –dysphagia, shortness of breath, voice change
  • How it was found (most are incidental)
  • • Cervical lymphadenopathy
    o Skin lesions
    • Clinical assessment of lesion (what do you think it is)
    • Local lymph node involvement
    o Soft tissue tumour
    • How long present
    • Change in size
    • Symptoms
    • Neurovascular involvement clinically

     

    4. Common question-specific information required
    o Lymph node biopsy we prefer to perform under general anaesthetic particularly if they are deep, cervical or not palpable
    o Mesenteric lymph nodes can be biopsied laparoscopically
    o 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.

     

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

     

    6. Medications relevant to consultations to this Specialty
    Blood thinners

     

    7. Essential Investigations required for specific consults
    o Lymph node biopsy
    • Imaging (ideally CT)
    • FBC – some patients are pancytopaenic which needs correction prior to surgery
    o Thyroid nodules
    • TFT/CMP
    • Thyroid US
    • FNA (prefer Austpath)
    o Skin lesions
    • Usually nil unless clinical signs of lymph node involvement
    o Soft tissue tumours
    • CT/MRI of region of concern
    • Do NOT arrange core biopsy unless asked

     

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

     

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

     

    Immunology

    1. Mechanism for requesting a consult

    Page the Clinical Immunology Registrar #22535

    NB: Pages may not be received by the Clinical Immunology Registrar on Tuesday between 9am-1pm due to poor paging system reception in Clinic G. Should your page not be returned during this time window, consider phoning the Clinical Immunology registrar on their mobile phone via Switch.

     

    2. Common questions/reasons for consults to this Specialty
    o Anaphylaxis/allergy
    o Autoimmune disease
    o Drug desensitisation
    o Immunodeficiency (primary/secondary)

     

    3. Common question-specific information required
    o Anaphylaxis/allergy
    • Suspected agent
    • Current medications
    • Allergy related symptoms
    o Drug desensitisation
    • Drug for desensitisation
    • Clinical indication
    • Lack of alternative agents
    o Autoimmune disease
    • Suspected disease
    o Immunodeficiency
    • Onset
    • Associated infections

     

    4. Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc)
    o Essential
    o Previous letters
    o Specialist contact
    o Helpful
    • blood test results
    • Autoimmune disease – autoimmune serology (e.g. ANA, ENA, ANCA, ESR, CRP, C3, C4 etc.)
    • Allergy/anaphylaxis – serum tryptase 2hrs and 24hrs post event, C4 level

     

    5. Family/social history relevant to consults to this Specialty
    o Helpful
    • Allergy/anaphylaxis
    • Family history of atopy (eczema, hayfever, asthma)
    • Autoimmune disease
    • Family history of any such conditions

     

    6. Medications relevant to consultations to this Specialty
    o Allergy/Anaphylaxis
    • Antihypertensives
    • ACEI use
    o Autoimmune disease
    • Systemic immunosuppression
    o Immunodeficiency
    • Systemic immunosuppression

     

    7. Essential Investigations required for specific consults
    o See section 4
    o Immunodeficiency – HIV serology

     

    8. Common problems in calls for consults
    o Poor drug history
    o Inability to describe pertinent symptoms of anaphylaxis/allergy

     

    Infectious Diseases

    1. Mechanism for Requesting a Consult
    There are three registrars – one for medical consults, one for surgical and one for ICU/Haem patients. Unfortunately this is not reflected on the roster, therefore when contacting the speed dial ask who the relevant person you need to contact is In general surgical pager is 9205 and medical pager is 8945 The phone is very busy, so if you cannot get through, leave a contact number via the ten second message prompt. Calling switch will not necessarily get us faster!

     

    2. Common questions/reasons for consults to this Specialty
    • Empiric antibiotic therapy
    • Targeted antibiotic therapy
    • Duration of antibiotic therapy
    • Fever ?source

     

    3. General clinical information/questions relevant to consults to this Specialty
    • Fever – onset, course
    • Septic screen
      – UA, urine MC&S, CXR, Bcx3 (ideally before ABx)
    • Imaging results
    • Previous and current microbiology results
      – Source, organism and sensitivities, treatment
    • Antibiotic therapy
      – IV & PO drug, dose, dates, reason for changing

     

    4. Common question-specific information required
    • Surgical procedures and intra-operative findings
    • Is there any prosthetic materials underlying that is it still in situ
    • Future surgical plans
    • Current and previous immunosuppression
    • Duration of neutropenia and expected recovery

     

    5. 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
    • Previous Infections and microbiology
    • MRSA, VRE and MRGN screen results
    • Immunosuppression
    Context-specific Sick contacts
    • Overseas travel
    • Bush contact
    • Animal contact

     

    6. Family/social history relevant to consults to this Specialty
    Essential
    • Occupation
    • Smoking
    Helpful
    • Vaccinations
    • IVDU
    • Sexual history

     

    7. Medications relevant to consultations to this Specialty
    • Antimicrobials (knowing start and stop dates is useful)
    • Immunosuppression
    • Warfarin & other drugs with interactions

     

    8. Investigations relevant to consultations to this Specialty
    • FBC, CRP. CRPs are not required daily 1-3x a week is sufficient
    • Renal function, liver function (for drug side-effects and dosing)
    • Microbiology
    • Imaging

     

    9. 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 (Xray/MRI), arterial or venous disease, DVT
    • UTI
        IDC-associated UTI: Urine sample needs to be collected via a fresh catheter Asymptomatic bacteruria is not always treated

     

    10. Common problems in calls for consults
    • Check therapeutic guidelines before calling
        eTG is available via CIAP. Many questions are answered here.
    • Check & read our intranet guidelines
        Excellent document on vancomycin dosing (and many other drugs)
    • When a question relates to sensitivities eg. oral options,
        it is worthwhile contacting the microbiology registrar first
    • You can also discuss with your ward pharmacist regarding dosing, they are very helpful
    • Charting vancomycin after 10/11am (so dose at 11am and 11pm) may be easier if you would like the morning phlebotomist to collect your trough vancomycin level.

     

    Dec 2016

     

    ICU


    How to initiate a patient referral to Westmead Intensive Care Services in 2018
    Note this guidance is different to 2017 and is likely to be different again in 2019 (with redevelopment changes)

    • Intensive Care Services (ICS) has a 24/7 referral mechanism for Westmead Hospital (and outside referrals)
    • ICS provides team leadership to the ALS team and attends in a time sensitive fashion.
    • In 2018, this is supplemented by increased ICS senior presence in the Surgical and Medical High Dependency Units during ‘Business Hours’
    • When able, the ICU currently provides a limited capacity to provide advice to ward-based patients with priority given according to patient acuity.  This does not replace the responsibility and working arrangements of the Primary team (in-hours) and the existing medical and surgical after-hours cover.

    URGENT REFERRAL
    IF THE PATIENT MEETS THE CRITERIA FOR AN ALS CALL, THEN INITIATE AN ALS.
    Senior members of the Primary Team must remain with the patient to assist the ALS team.

    EMERGENT REFERRAL
    The referral pattern depends upon the geographical location and time of day.
    The most senior member of the Primary team (Fellow, Consultant) should make this referral in a timely fashion.

    • High Dependency Areas (Medical and Surgical)
      M-F 0800 to 1800 (exc public holidays), contact the Level 1 ICU Consultant (details in the High Dependency areas).
      Outside these hours, contact pager 8620.

    • Emergency Department, Operating Theatre or Out-of-Hospital referrals 
      All hours: must be made to pager 8620.

    • Other wards
      Patient management on the wards remains the responsibility of the Primary Team (in hours) and the after-hours Medical/Surgical Team (Registrars and RMOs).
      An appropriate referral to ICS would be if a patient genuinely needs an escalated level of care requiring either ICU or HDU.  This may be after multiple Medical/Surgical Registrar reviews and/or PACE calls.
      Please page 8620 bearing in mind lower acuity patients will be prioritised accordingly.
      Booked “Elective’ Admissions

    • Cardiothoracic Surgical Patients have their own booking mechanism for ICU beds.

    • Non-Cardiothoracic Surgical Patients booked on the day of surgery must be booked with Pager 8620. ‘Elective’ admissions booked on the day of surgery will have a lower priority than Urgent and truly Emergent patients.

    • Booking a patient before the day of surgery
      Bring the patient details to the ICU Zone B, fill in a Patient Referral sheet.
      Discuss with the ICU Senior Medical Staff (Consultant or Senior Registrar) .
      On the day of surgery
      Confirm the availability of the ICU bed after 0730 with the ICU NUM (extn 5-9448 or 5-9465) or Pager 8620.
      If the ICU bed is NOT required, please inform the ICU NUM as soon as possible.


    Nov 2017

    Kidney Transplant Medicine

    1. Mechanism of requesting a consult
    • Patients who have kidney or kidney-pancreas or islet cell transplant
      • In hours – call day/team transplant registrar
      • After hours – call the transplant consultant on call
      • On call transplant registrar only for new transplants returning from theatre
    • Please contact transplant team ASAP if any concerns (day or night).
      • We would be happy to guide investigation and management to rectify issues earlier rather than later. Please do so urgently even before any results are back if there is any pain over the transplant or the patient is oligouric/anuric.
    • Non transplant patients – call the haemodialysis AT or nephrology BPT accordingly

     

    2. Common questions/reasons for consults to this Specialty
    • After hours reviews and concerns regarding any transplant patients.
    • Particular concerns for acute transplants: fever, hypotension, sudden drop in urine output, graft tenderness, hyperglycemia (if pancreas transplant)
    • Advise that a patient with a transplant is admitted under another team
    • Immunosuppressant management

     

    3. General clinical information/questions relevant to consults to this Specialty
    • Reason for admission and key exam findings/investigations/management plans
    • Observations (temperature, sats, RR, HR, blood pressure)
    • Fluid status, graft tenderness, urine output

     

    4. Common question-specific information required
    • Date of Transplant and transplant unit (eg kidney – pancreas transplant 2010)
    • Underlying renal disease (eg IgA nephropathy)
    • Transplant complications (eg previous rejection, strictures, infections)
    • List of medications and any changes, particularly if the patient is on:
      • Tacrolimus or cyclosporine, prednisone
      • Mycophenolate or azathioprine or everolimus
      • Resprim or Bactrim, valganciclovir
      • Anti platelet or anticoagulation, anti hypertensives
      • Any allergies to medications
    • Key investigations for transplant patients
      • Kidney transplant – K, HCO3, Ur, Cr, eGFR, albumin, Hb, WCC, Plt, CRP
      • Kidney pancreas transplant – above + blood sugar and amylase levels
      • Islet cell transplant – above + blood sugar + C-peptide
      • Microbiology results if available – eg urine and blood cultures, CMV PCR
      • Tacrolimus or cyclosporine levels
      • Renal transplant ultrasound if available or requested

     

    5. Background Medical History relevant to consults to this Specialty
    • If transplanted at a different hospital – date and hospital of transplant. They will have data on Past med hx and transplant related issues.
    • Recent Travel history, sick contacts, recent surgery or medication changes

     

    6. Family/social history relevant to consults to this Specialty
  • Any changes in circumstances

     

    7. Investigations relevant to consultations to this Specialty (and why)
    • Renal ultrasound – excludes obstruction, demonstrates vascularity
    • CXR, urine MCS, blood cultures as minimum in febrile patients
    • Tacrolimus levels – level of immunosuppression or tacrolimus toxicity

     

    8. Common problems in calls for consults
    Getting an early consult – even if the transplant seems irrelevant it may well not be!

     

    9. Extra tips for acquiring consults
    DON’T wait to investigate if the kidney is not functioning – call us immediately
  • Transplant registrar during hours
  • Transplant consultant on call after hours
  •  

    Neurology

    1. Mechanism for requesting a consult
    - For patients with a possible acute stroke (e.g. acute focal neurological
    symptoms/signs with onset less than 6 hours ago):
    - contact the Stroke Registrar 0400880178
    For patients in the Emergency Department not yet admitted:
    - contact the Neurology Registrar for ED
    For consults on patients admitted under another service:
    - contact the Neurology Registrar for consults
    If unable to reach the above contacts:
    - contact the Neurology Advanced Trainee

     

    2. Common questions/reasons for consults to this Specialty
    • Whether something is a seizure (vs other causes)
    • Parkinson’s Disease management
    • Headache
    • Seizure management

     

    3. General clinical information/questions relevant to consults to this Specialty
    Essential
    • If patient well known to a particular neurologist
    • The history is most important - basic knowledge of symptoms and their duration
    • A basic neurological examination
    • Accurate medication history particularly antiepileptics and doses
    • What question the treating team would like answered
    Helpful
    • MMSE in the case of cognitive impairment
    • Drug levels of any antiepileptic drugs
    • Letters from their treating neurologist
    • If they have any recent neurological imaging or EEG externally and what it shows

     

    4. Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc)
    Essential
    • History of major neurological illness (stroke/MS/epilepsy etc)

     

    5. Family/social history relevant to consults to this Specialty
    Helpful
    • Family history epilepsy
    • Drug and alcohol use

     

    6. Medications relevant to consultations to this Specialty
    • Antiepileptic doses
    • 
Parkinson’s medications

     

    7. Investigations relevant to consultations to this Specialty
    • CT and MRI of brain/cord
    • EEG
    • EMG/nerve conduction
    • Antiepileptic drug levels
    • Inflammatory markers
    • Basic bloods
    • CSF

     

    8. Investigations relevant to consultations to this Specialty (and why)
    • MRI or CT brain looking for underlying structural cause of explain symptoms
    • NCS/EMG
    • EEG particularly in case of first seizure
    • CSF (especially for headache, possible CNS infection)

     

    Dec 2016

     

    Neurosurgery

    1. Mechanism for Requesting a consult
    • In hours (8am-5pm): Page #08777 for the on call neurosurgery registrar
    • After Hours: Ring the on call neurosurgery registrars mobile via the switch
    • Emergency: Ring the on call neurosurgery registrars mobile via the switch

     

    2. Common questions/reasons for consults to this Specialty
    Brain:
    • Head injury
    • Tumours (primary and secondary)
    • Intracerebral haemorrhage (ICH) - EDH,SDH,SAH,IPH,IVH
    • Crainial Infections
    • Vascular -  aneurysms, AVMa dAVFs
    • hydrocephalus - Shunts, NPH
    • INR - Cerebral angiograms, intracranial coiling and stenting
    Spine:
    • Spinal injury
    • Spinal cord compression / Cauda equina syndrome
    • Tumours - bone, extradural, intradural, intramedullary
    • Infections
    • Degenerative spine disease
    Others
    • Carpal tunnel decompression
    • Muscle biopsies
    • Nerve biopsies
    • Peripheral nerve tumours
    In addition to the generic advice below you can CLICK HERE to download very specific advice about consults on each of the following above conditions

     

    3. General clinical information/questions relevant to consults to this Specialty
    It’s always helpful to start the consult with a brief statement that sums up the issue and what is required of the consult eg:
    • I have an 80 year old who sustained a fall who has a subdural. They are GCS 15 and taking aspirin for AF.
    • We are after some advice on an 18 year old involved in a MVA with no neurological deficit and an L1 fracture on xray.

    Essential
    • Age & functional status
    • History relating to the presenting issue
      • Time course of symptoms
      • Associated symptoms
      • May include history from family/friends
    • Past Medical History
      • Adjuvant treatments in malignancy
      • Genetic conditions
      • Significant organ dysfunction that can impact on anaesthetic risks
    • Past Surgical History
      • Especially cranial and spinal operations – track down details if not completed in Westmead
      • Chest and/or abdominal surgery is important to note in cases of shunts or hydrocephalus
    • Social History – smoking, alcohol, drugs
      • Functional status – living alone, at home, nursing home
        • Eg mobility status, independence
        • Social supports
        • Occupation
      • Impairments due to the referring issue
        • And other medical conditions that impair their functional abilities
    • Family History – esp in vascular cases and those with genetic diseases

    • Contemporaneous neurological assessment
      • Focus on the presentation
      • Include:
        • GCS, including the component scores (E1-4, V1-5, M1-6)
        • Cranial nerve examination (for any cranial related issues)
        • Limb examination (tone, power, sensory, reflexes, +/- PR)

      Helpful:
      • Patient wishes or AHDs
        • Previous functional status in the elderly or those with sever co-morbidities
          • This may impact on the type of surgery offered
        • Expectations of patient can be important to consider
      • Other speciality opinions
        • Esp for malignancy issues
        • Infectious diseases in any suspected infection

     

    4. Common question-specific information required
    • For back pain with leg pain (or neck and arm pain): the time frame of the pain, any weakness or numbness. Any bowel or bladder function compromise.
    • For headaches with a concern re: ?SAH – clear history of the onset and severity of the headache. Presence or absence of signs of meningism: neck stiffness, photophobia.
    • For shunt patients: previous surgery, patterns of symptoms and signs with previous shunt blockages, collateral history from parents or partner or carer very important
    • For any tumour patient – history of previous malignancy, any surgical and adjuvant therapy – chemo, radiotherapy, and who has been involved in their care

     

    5. Medications relevant to consultations to this Specialty
    • Esp antiplatelets and anticoagulants
      • And their indications (this can be helpful in deciding how long to withhold)/li>
    • Analgesia in cases of severe pain (eg degenerative disc disease)
    • Chemotherapy and/or immunotherapy in cases of malignancy

     

    6. Investigations relevant to consultations to this Specialty
    • Recent Laboratory Studies
      • Esp Hb, Plts, Na, Coags
      • WCC and CRP in cases of infection
      • LFTs can be important in those with liver disease, large EtOH intake or long term hepatotoxic medications
    • Imaging
      • When describing imaging, the salient points are all that are required
        • When and where the imaging was done
        • What imaging modality it is
        • When describing lesions, make sure to include:
          • Side (right vs left) and site (frontal, parietal, temporal, occipital, cerebellar)
          • Or level in spine issues
          • Size (of the lesion and if MLS present how much)
          • What – EDH, SDH, SAH, tumour, abscess, disc prolapse
          • If there’s an underlying cause it is also important to mention (eg aneurysm, AVM, fracture)
          • Any other important findings (other injuries)
      • If an MRI is likely to be requested, it is important to find out that there are no contradictions or if the patient will require sedation
        • Both these impact and delay workup
      • If organising an MRI where the patient is likely to go to theatre soon (within days), it is important to order not only the diagnostic imaging, but a “STEALTH protocol with fiducials” so as to save another MRI pre-op.
        • The Neurosurgery intern or resident can be called to place the fiducials before the MRI

     

    7. Investigations relevant to consultations to this Specialty (and why)
    • MRI brain – often with ‘stealth protocol’ – for anyone with a brain tumour who will be having an early operation
    • MRI Spine – in cord or cauda equina compression but also in selected cases of radiculopathy and in spinal fractures where ligamentous injury is suspected
    • Flexion/extension x-rays – used to assess stability of spine in cases of radiologically normal C-spine or suspected spondylolisthesis elsewhere
    • Erect spinal x-rays – often used to assess alignment in case of fractures being managed in a spinal orthosis (or brace) such as a TLSO
    • Blood tests: Coagulation studies, FBE (especially platelets), EUC (especially Na), group and save, anti-convulsant levels, LFTs (especially in patients on long-term anti-consultants or chemotherapy agents
    • EEG: in patients with proven or suspected seizures

     

    8. Common problems in calls for consults
    • With increasing frequency we have been receiving phone calls from junior doctors who have been instructed to phone neurosurgery about a patient they have not examined. This is really unhelpful and potentially unsafe. In general it is necessary to do a focused examination before calling neurosurgery with a consult.
    • Keep it brief and to the point, emphasize positive history point and positive clinical findings and summarize scan findings early in the discussion. Make it clear what the question is that you want the answer to

    Obstetrics and Gynaecology

    1. Mechanism for obtaining a Consult
    • On-call O&G registrars carry a common pager (Pg. #9171) dedicated to consults from the ED and other inpatient areas
    • This pager is accessible through the routine paging system and is manned during all hours of the day
    • As O&G is a surgical specialty and the on-call registrar is also responsible for dealing with OT cases, there may occasionally be a delay in response. In this case, options include:
      • Paging again again at a later time if not urgent
      • Contacting the Birth Unit registrar in the event of an obstetric emergency (Pg. #8867)
    •  

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

       

      3. General clinical information/questions relevant to consults to this Specialty
      Essential
      • Menstrual history incl. LMP, frequency, regularity and amount of flow. Menopausal vs pre-menopausal
      • Sexual history, incl. contraception history
      • Pregnancy status
      • Past obstetric and gynaecological history incl. surgery
      • Pap test history
      Helpful
      • Contraception? What type?
      • Systemic symptoms

       

      4. 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 investigations: USS/CT

       

      5. Family/social history relevant to consults to this Specialty
      Essential
      • Family history of uterine/ovarian/breast/bowel cancer

       

      6. Medications relevant to consultations to this Specialty
      • Contraception or other hormonal treatments
      • Fertility treatments: e.g. Clomiphene citrate
      • HRT
      • Tamoxifen

       

      7. Investigations relevant to consultations to this Specialty
      • Serum or urine BHCG
      • Pelvic USS (TV preferred)
      • FBC (if PVB)
      • CRP (if? PID)
      • Swabs of lower genital tract

       

      8. Essential Investigations required for specific consults
      As above

       

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

       

      10. 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.

       

      Dec 2016

       

    Ophthalmology

    1. Mechanism for requesting a consult
    • Page 22511 (on-call registrar) for urgent consults.
    • Requests for outpatient consults can be made on a hospital consult form, and dropped into the Eye Clinic physically, or faxed to 8890 3874, and we will contact the patient with an appointment date. Requests must include a current best corrected visual acuity (or reason why this cannot be obtained) or they will be returned to be completed.

     

    2. Common questions/reasons for consults to this Specialty
    • Trauma reviews
    • Orbital or periorbital cellulitis
    • Acute changes in vision, acute red eye, or acute eye pain
    • Possible giant cell arteritis with visual symptoms
    • Screening for occult infections in patients with blood cultures positive for fungus or Klebsiella pneumonia
    • Neurological problems with visual symptoms (eg optic neuritis, double vision from cranial nerve palsies, blurred vision and headache)
    • Orbital inflammatory diseases eg thyroid eye disease

     

    3. General clinical information/questions relevant to consults to this Specialty
    It is essential to have a clear understanding of why you are obtaining a consult prior to contacting the on-call registrar. If in doubt, try to summarise your opening remarks using the ISBAR format:
    • “Hello, this is John the cardiology intern”
    • “I need a consult for Mr John Smith MRN 1234567 bed D3c/34 who has new onset blurry vision and pain in his right eye”
    • “He has recently had cataract surgery, but was subsequently admitted with a NSTEMI. His vision is reduced to count fingers and his eye is red.”
    • “I am concerned about post-operative endophthalmitis”
    • “I need you to see him today”

    Requests for “general reviews”, “vision checks” or reviews of chronic conditions managed externally will be met with opposition! If in doubt, ask your registrar or consultant why they want us to see the patient, and what they need us to do.

     

    Essential
    • Summary of issue of concern
    • Ocular symptoms – blurred vision, abnormal vision (eg floaters, flashes), visual field defect, pain, redness, photophobia
    • Associated symptoms – headache, jaw/tongue claudication, nausea/vomiting, fever, weight loss
    • Timeframe of development or symptoms
    • Previous treatment of current issue
    • If admitted for another reason, accurate summary of current presentation and issues

     

    4. Common question-specific information required
    • If symptoms of flashes/floaters/shadows: Previous retinal detachment? Operations?
    • For? GCA: ask about headache, temporal scalp tenderness, jaw claudication, night sweats, loss of weight, should pain, pre-existing Polymyalgia rheumatica. If suspected, do urgent ESR, CRP, and FBC (high platelet count). If VA poor, expect to find RAPD on affected side.
    • For orbital fractures, eye movements, pupils reactive (any mydriasis or hyphaema). Usually require CT orbits + facial bones to confirm extent of orbital fractures.
    • For? Acute angle closure glaucoma: Poor vision? Haloes around lights? Acute onset lateralised headache/eye ache? Nausea or vomiting? Allergies (particularly sulfur)? Previous surgery or laser? Pupil reaction? Clear cornea?

     

    5. Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc)
    Essential
    • Recent eye operations/laser/injections? When?
    • Previous eye trauma?
    • Seen optometrists or ophthalmologists recently? If yes, why? Reports?
    • Glasses? Contact lenses? Laser surgery?
    • Red eye: Contact lens wear? Previous keratitis?

     

    6. Family/social history relevant to consults to this Specialty
    • Glaucoma: Positive family history
    • Smoker? ETOH?Drug use? Driver (commercial or private)?

     

    7. Medications relevant to consultations to this Specialty
    • Eye drops (past and current)
    • Previous eye injections (including date of most recent injections)
    • Allergies to sulphur or antibiotics?

     

    8. Investigations relevant to consultations to this Specialty
    • ESR, CPR, and Platelets for ?GCA
    • CT Orbits + Facial Bones for orbital wall fractures
    • CT or MRI brain for bilateral visual field defects

     

    9. Essential Investigations required for specific consults
    All consults require a basic ophthalmic examination be conducted by the referring team. This includes:
    • Mono-ocular best-corrected visual acuity (Snellen - 6/xx).
      • Use distance glasses and test at 6m.
      • Use pinhole correction if glasses unavailable or old.
      • If only able to test at near, use an appropriate reading chart, and reading glasses.
    • Pupil reaction, any RAPD (relative afferent pupillary defect)?
    • Eye movements? Diplopia?
    • Visual fields to confrontation?
    • Proptosis?
    • Ptosis?
    • Attempted slit lamp examination if in emergency, otherwise macroscopic examination of eye (“we haven’t looked” is not acceptable)

     

    9. Common problems in calls for consults
    • No visual acuity measurement attempted prior to requesting consult
      • This is like contacting cardiology without doing an ECG, or O&G without doing a pregnancy test
      • “We don’t have a Snellen chart” is no excuse. There are apps (eg “Eye Chart”) that one can download onto smart phones to be used for visual acuity assessment. Physical photocopies of Snellen charts are in Eye Clinic that you can take.
    • We will not be able to assess visual acuity or eye movements if patients are intubated, delirious or obtunded - these are subjective tests requiring patient feedback
      • We can still examine these patients for signs of significant ocular trauma or objective disease
    • We cannot reliably assess the retina, or look for papilloedema, if patients cannot be dilated (usually because of a requirement for neurosurgical observations)
      • Subjective visual acuity and confrontation visual field testing can be performed, and we can still examine the anterior segment of the eye.
    • We can only conduct a limited assessment of a patient on the ward. A full assessment (including formal visual fields) requires patients attend our clinic. Some patients are unfit to attend the clinic:
      • Intubated or sedated patients
      • Patient with central lines that are not heparin-locked
      • Patients with blood products being infused
      • Patients on continuous cardiac monitoring
      • Patients with arterial lines, chest drains, or large wound drains
      • Haemodynamically unstable patients, or recent PACE/ALS calls
      • Bed bound patients
      • Floridly delirious patients
      • GCS < 14
    • Unwell patients coming to clinic require a nurse escort from the referring ward
      • All requests for transfer to our clinic need to be made via our nursing staff. Do not transfer patients directly to our clinic without first discussing with us.
      • Some ophthalmic problems are urgent (endophthalmitis, acute angle closure glaucoma, suspected penetrating eye injury or globe rupture, orbital cellulitis, acute third nerve palsy, giant cell arteritis, papilloedema). If you are querying these diagnoses, specifically mention this in the consult to enable appropriate triage.

     

    10. Extra tips for acquiring consults
    • Non-urgent problems are best assessed in our outpatient clinics. Limit inpatient consults to acute issues only.
    • Patients in referral hospitals must attend the eye clinic (or Westmead Emergency if after hours) for a review. Only in extreme circumstances is it possible for review to be arranged outside Westmead. Contact us if unsure.
    • Patients under 16 should be referred to Westmead Children’s Hospital.

    Orthopaedics

    1. Mechanism for requesting a consult
    • 0800-1700: page#8782
    • 17:00-0800: call switch and ask for the Orthopaedic registrar on cal

     

    2. Common questions/reasons for consults to this Specialty
    o Trauma
    o Tumour
    o Septic arthritis
    o Spinal injury

     

    3. General clinical information/questions relevant to consults to this Specialty
    o Essential
    • Age
    • Mechanism of injury open / closed / dislocated
    • If upper limb injury: R or L hand dominant
    • Underlying pathology
    • Medical comorbidities
    • Other injuries
    • Insurance Status: Private/work-cover/medicare/CTP etc
    o Helpful
    • Anticoagulation status
    • Stable / unstable in resuscitation bay in ED
    • Blood indices

     

    4. Common question-specific information required
    o Essential
    • Physical examination findings: active and passive range of motion etc
    • Pain profile history
    • Weight bearing status
    • Obvious X-ray findings
    • Known tumour / previous treatment
    • ESR /CRP/ previous micro results
    • Neurological deficit and mobility

     

    5. Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc)
    o Essential
    • Previous orthopaedic consultant involved
    • Any management plan already on place
    • Letters from discharge or rooms consultation
    • Postoperative complications and consults
    • Previous imaging
    • Other prostheses/implants in situ
    • Allergies
    o Helpful
    • Prognosis
    • Recurrence
    • Other teams involved

     

    6. Family/social history relevant to consults to this Specialty
    o Essential
    • Baseline mobility and cognition
    • Living arrangements and family support
    • Ability to consent if family members acting on behalf of patient
    • Smoker status
    • Alcohol dependence
    • Drug dependence
    o Helpful
    • Occupation

     

    7. Medications relevant to consultations to this Specialty
    o Warfarin
    o Aspirin/Clopidogrel
    o NOACs
    o Antibiotics
    o Bisphosphonates

     

    8. Essential Investigations relevant to consultations to this Specialty
    o XR
    o FBC/CRP/ESR/blood cultures (if ? septic arthritis)
    o X-ray
    o Joint aspirate if concerned about septic arthritis (arrange US guided aspirate if team no confident to perform on ward). Send aspirate for cell count and differential, Gram stain, culture , crystal analysis
    o MRI CT

     

    9. Essential Investigations required for specific consults
    o X-ray for fractures
    o Bone scan for infection or tumour
    o MRI for unclear NOF fracture
    o CT +/- MRI for spinal injury 9. Investigations often requested (and why)
    o XR / CT to detail bony injury and articular involvement
    o FBC/ EUC/ ESR/ CRP/ Coagulation studies likely for preoperative workup
    o MRI to identify ligamentous injury

     

    10. Common problems in calls for consults
    o History not clear.
    o Doctor calling for the consult has not actually examined the patient themselves
    o Basic investigations not done.
    o Need to state primary reason for consult early in the phone call
    o Not every patient with osteomyelitis needs Orthopaedic involvement. Need to state clearly what the consult is for: bone biopsy to guide antibiotic treatment, presence of sequestrum etc
    o Consults to report X-rays are NOT appropriate and should be directed to the Radiologist on call.

     

    11. 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.

     

    Oral and Maxillofacial Surgery

    1. Mechanism for requesting a consult

    Page #9244

     

    2. Common questions/reasons for consults to this Specialty

    o Facial fractures
    o Facial infections

     

    3. General clinical information/questions relevant to consults to this Specialty
    Facial fractures
    o Essential
    • Mechanism of injury
    • Other injuries sustained
    • Significant medical comorbidities and medications: eg anticoagulants
    • Zygoma/ orbital fractures: pupil status, visual acuity, range of eye movements, presence of diplopia?
    • Mandible fractures: occlusion, dentate/ edentulous
    o Helpful
    • Fasting status
    Facial infections
    o Essential
    • Any signs or symptoms of airway compromise
    • Duration of signs & symptoms
    • Medical comorbidities
    • Treatments received so far
    • Likely source of infection (cutaneous or odontogenic)
    • Degree of trismus eg how many centimetres
    • Floor of mouth – soft or indurated
    • Size and location of swelling, soft tor firm on palpation
    o Helpful
    • Fasting status
    • Inflammatory markers

     

    4. Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc)
    o Essential
    • Diabetes, immunosuppression status
    • Previous management of same condition
    o Helpful
    • Hep C, HIV status if applicable

     

    5. Family/social history relevant to consults to this Specialty
    o Essential
    • Smoking
    • Recreational drugs & alcohol use

     

    6. Medications relevant to consultations to this Specialty
    o Anticoagulants
    o Immunosuppresants

     

    7. Essential Investigations required for specific consults
    o CT orbits/ facial bones for midface/ zygoma/ orbital fractures
    o OPG + PA mandible for mandible fractures
    o CT with contrast for facial space infections
    o Inflammatory markers for infections +/- blood cultures if febrile

     

    8. Common problems in calls for consults
    o Requesting consultations for patients with deep facial space infections with only plain radiographs such as OPGs. Plain radiographs do not give you information on soft tissue.
    o Facial lacerations should be covered with non-adhering dressings to avoid wound desiccation 9. Extra tips for acquiring consults
    For non-urgent consults, please avoid calling the on-call between 2300 and 0630.

     

    Palliative and Supportive 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.

    1. Mechanism for requesting a consult

    Page #9323

     

    2.Common questions/reasons for consults to this Specialty

    o Difficult symptom management in anyone with life-threatening illness, e.g. pain, dyspnoea, anxiety, nausea and vomiting. Symptom control eg pain, nausea
    o Decision-making in complex life threatening illness where the outcome is uncertain o Specific information regarding PCU and complex discharge
    o End of life care
    o Take over care
    o Community “link up” NOT A HELPFUL REASON FOR CONSULT and should be discussed with the CNC on pager #8755
    o Advanced care planning discussions

     

    3.General clinical information/questions relevant to consults to this Specialty
    o Essential
    • Diagnosis
    • Prognosis
    • Patient and family understanding of diagnosis and stage • Patient and family understanding of goals 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
    o Helpful
    • Family dynamic
    • Social situation
    • Community support

     

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

     

    5.Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc)
    o Essential
    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
    Co-morbidities impacting on current illness
    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

     

    6.Family/social history relevant to consults to this Specialty
    o Essential
    • Family / social supports
    • 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.

     

    7.Medications relevant to consultations to this Specialty
    o Analgesics
    o Anti-emetics
    o Aperients

     

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

     

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

     

    10. Common problems in calls for consults
    o Reason for referral – often the referring Dr eg intern has no idea
    o No clear goals of care
    o No advanced medical plan completed
    o 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. o No consult request sheet completed

     

    11. Extra tips for acquiring consults
    o Know why the consult has been requested
    o Give an appropriate clinical picture to the registrar taking the call
    o Have all relevant clinical information at hand when phoning so can quickly answer questions, especially the medication chart and have powerchart open
    o If patient is to be discharged to a ACF/Nursing Home, call the Palliative Care ACF outreach CNS Ray Wilcox 0419 335 667
    o If advice is only concerning home discharge planning, page the Palliative Care CNC Harriet Van de Pol #8755. This is for advice. The CNC will NOT do the discharge planning, referrals 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

     

    Plastic Surgery

    1. Mechanism for requesting a consult
    • Page the consult pager on #8339 between 7am – 5pm
    • If unsuccessful, please call the mobile phone of the senior Westmead Hospital registrar via switch
    • On occasions, the pager may not be answered whilst in the operating theatre. If this is the case, please call Operating Theatres on 56566 and ask to be put through to the Plastic Surgery Theatre.

     

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

     

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

     

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

     

    5. 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?

     

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

     

    7. Medications relevant to consultations to this Specialty
    • Immunosuppressants
    • Anticoagulants
    • Antibiotics
    • ADT up-to-date?

     

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

     

    9. 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)

     

    10. Investigations relevant to consultations to this Specialty (and why)
    • X-ray
    • OPG and PA mandible – should be requested in addition to CT so that follow up may be made with repeat OPG and not repeat CT

     

    11. Common problems in calls for consults
    • Unable to describe a laceration, or fracture on x-ray (stating ”the MCPJ or IPJ looks funny” is not helpful)
    • Accurate/anatomical descriptions of hand and facial injuries is appreciated.

     

    Dec 2016

     

    Radiation Oncology

    1. Mechanism for Requesting a consult
    There are six registrars in radiation oncology at Westmead Hospital, one at Blacktown and two at Nepean. Each trainee covers more than one consultant.
    Page the on-call registrar and inform them of the primary site (eg prostate cancer) and the presenting problem (eg MSCC) and they will direct your consult appropriately and /or obtain the relevant patient information.

     

    2. Common questions/reasons for consults to this Specialty
    o Malignant spinal cord compression (MSCC) o Bleeding (GIT/PV/PR/fungating tumour)
    o Brain metastasis
    o Pain
    o SVC/airway obstruction

     

    3. General clinical information/questions relevant to consults to this Specialty
    o Essential
    • Histological confirmation of malignancy and primary site whenever possible
    • Presenting problem and reason for admission
    • Consults obtained from other specialties and outcome
    • Stage at initial diagnosis
    • If progression of disease – time to progression
    • Sites of metastatic disease (i.e burden of disease)
    • Patient performance status (i.e ECOG)
    • If an interpreter is required
    o Helpful
    • Stage at initial diagnosise
    • If there is progression of diseases - time to progression
    • Sites of metastatic disease (ie burden of disease)
    • Can the patient lie supine (treatment position for treatment)

     

    4. Common question-specific information required
    o For MSCC an important prognostic factor is ambulatory status. Ensure neurological examination is done. It is also important to note that pain often precedes neurological dysfunction and is the most common presenting symptom.
    o If bleeding from malignant site total units of blood transfused and days between transfusion as well as current Hb results.

     

    5. Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc)
    o Essential
    • If known to a Radiation Oncologist
    • Prior history of radiation (site and dose)
    • If patient is known to a Surgical or Medical Oncologist • Prior chemotherapy and date of last chemo cycle
    o Helpful
    • If prior radiation treatment at another institution faxed information of prescription • Contraindication to radiotherapy e.g scleroderma, SLE
    • If young female rule out pregnancy

     

    6. Family/social history relevant to consults to this Specialty
    o Essential
    • Language barriers (i.e NESB)
    • Smoking history in terms of pack years
    • Significant family history of cancer
    • Social supports
    o Helpful
    • Next of kin

     

    7. Medications relevant to consultations to this Specialty
    o Analgesics
    o Dexamethasone
    o Cancerspecificoralmedication(e.g.tamoxifin,capcitabine)
    o Aperients
    o Anticoagulation
    o Immunosuppressant

     

    8. Investigations relevant to consultations to this Specialty
    o Recent CT staging
    o WBBS or skeletal survey(Multiple Myeloma)
    o MRI if indicated
    o Serum tumour markers

     

    9. Essential Investigations required for specific consults
    o FullspinalcordMRIwithgadoliniumforMSCC(toruleoutmultilevelcompression)
    o CTbrainwithcontrastforbrainmetastases
    o EndoscopyforGITbleeding

     

    10. Investigations relevant to consultations to this Specialty (and why)
    o MRI brain – 1-3 brain metastasis on CT. This depends on a number of factors including performance status and extent of extra-cranial disease. This is for patients that we are considering surgical resection or stereotactic radiosurgery. MRI is also done for primary brain tumours.
    o Plain X-ray film of site of bone pain or CT with bone window to assess risk of pathological fracture. Often we liaise with orthopaedic team regarding this.
    o PET scan in the initial diagnosis of certain malignancies e.g. primary lung cancer. It can be sometimes considered in situations where radiological studies are equivocal. Only order in consultation with oncology team.

     

    11. Extra tips for acquiring consults
    There are eight registrars in radiation oncology assigned to pairs of consultants (total of 12 consultants).
    If the patient is known to a Radiation Oncologist at Westmead or Nepean it is best to obtain the pager number of the registrar assigned to that consultant from switch for the consult.
    If the patient is not known to a Radiation Oncologist page the on-call registrar and inform them of the primary site (e.g. prostate cancer) and presenting problem (e.g. MSCC) and they will direct your consult appropriately and/or obtain the relevant patient information.
    The majority of cancer patients seeking opinion from a Radiation Oncologist are seen in outpatient clinics. Often when patients present initially their symptoms can be stabilised with medical management and histology confirmed by the surgical team. When a ward consult is obtained in this scenario we may occasionally direct you to give the patient an outpatient clinic appointment as clinically indicated. This allows the patient to attend with family members for complete assessments and to discuss in detail the complexities of treatment, often after a multidisciplinary meeting.

     

    Rehabilitation Medicine

    SPECIALTY: Rehabilitation Medicine (Amputees, Brain Injury, SMART, General)
    1. Common questions/reasons for consults to this Specialty
    o Advice on capacity to improve
    o Assess suitability for inpatient or outpatient rehabilitation
    o Assess decreased functional ability in patients
    o Clearance of PTA in patients with mild traumatic brain injury o Education and counselling of amputee patients

     

    2. General clinical information/questions relevant to consults to this Specialty
    o Essential
    • Current medical stability and status
    • Primary Care Team’s plans and follow up
    • Any outstanding procedures / surgery
    • Current functional limitations – mobility, communication, cognition and behaviour
    • PTA scores for brain injury patients
    o Helpful
    • Allied health assessments, i.e. PT, OT, speech path

     

    3. Common question-specific information required
    o Is the patient medically stable?
    o Are there any further planned procedures or treatment
    o What is the patient’s current level of function?
    o Is the patient engaging with ward therapists?
    o Is the patient improving?
    o What is the patient’s prognosis?

     

    4. Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc)
    o Essential
    • Diagnosis of any disabling conditions e.g. Parkinson’s disease, Motor Neurone Disease
    • Presence of any general medical illnesses e.g cardiac disease, respiratory failure
    • Prognosis of primary medical condition
    • Any cognitive changes or issues
    • Any drug and alcohol history
    o Helpful
    • Any previous rehabilitation intervention • Presence of pain with limitations

     

    5. Family/social history relevant to consults to this Specialty
    o Essential
    • Local Government Area (LGA) of residence
    • Living situation – who they live with and supports available
    • Any services in place?
    • Health insurance status – Medicare, private or compensable e.g. workers comp, motor accident insurance
    o Helpful
    • Employment Status
    • Home layout – single or double storey, external steps, bathroom access, etc • Income status

     

    6. Medications relevant to consultations to this Specialty
    o Sedatives
    o Analgesics/neuropathicagents
    o Steroids
    o IVmedicationse.g.Antibiotics
    o Antispasticagents
    o Anticonvulsants

     

    7. Investigations relevant to consultations to this Specialty
    o CT and MRI scans esp. brain
    o General X-Rays - orthopaedic
    o General blood screens

     

    8. Common problems in calls for consults
    o Consult requests made too late – often when patient is about to be discharged (even if not functionally safe for discharge)
    o Belief that Rehabilitation Medicine will take over care of all disabling conditions – this is not appropriate for some patients who have poor prognosis and little prospect for improvement 9. Extra tips for acquiring consults
    o Make referrals early – when it is clear that patient is likely to have functional limitations, even if not yet medically stable
    o Early rehabilitation assessment allows for earlier intervention and quicker hospital discharge and better patient outcomes.

     

    Renal & Dialysis Medicine

    1. Mechanism for requesting a consult
    Page the correct registrar
    • Patients who have renal transplant – contact transplant advanced trainee
    • Patients currently on haemodialysis – contact the haemodialysis advanced trainee
    • Patients on peritoneal dialysis, AKI, CKD or other consults – nephrology BPT
    • After hours (weekdays and weekends) – contact renal consultant on call

     

    2. Common questions/reasons for consults to this Specialty
    • Acute kidney injury
    • Electrolyte and acid/base derangement
    • Renal involvement in systemic disease
    • Peritoneal dialysis patients admitted under other teams
    • Haemodialysis patients admitted under other teams
    • Contrast nephropathy prophylaxis
    • Hypertension and preeclampsia
    • Drug dosing in kidney failure – contact pharmacist as first point of call

     

    3. General clinical information/questions relevant to consults to this Specialty
    As above, contact the correct registrar
    Correspondence from the nephrologist if available

    Key information
    • REASON FOR CONSULT: the clinical question (vs courtesy call)
    • Underlying cause of renal disease if known (eg IgA nephropathy)
    • If patient is on dialysis:
    • Duration on dialysis
    • Modality (PD or HD), days of dialysis if HD (eg M/W/F)
    • Usualy dry weight, residual urine
    • Major comorbidities (eg CCF, DM, HTN, SLE, liver disease etc)
    • Medication list – including medications that were ceased on admission
    • Brief summary of why the patient is currently admitted
    • Key exam findngs, investigations and treatment plans or results
    • Observations (BP, HR, sats, RR, temperature)
    • Fluid status + input (oral or IV), urine output, current weight
    • Urine analysis (dipstick) – check for blood/protein/leukocytes/nitrites
    • Current and baseline creatinine and eGFR if not on dialysis
    • Bloods: Na, K, HCO3, Ur, Cr, eGFR, albumin, Ca, PO4, Hb
    • Renal imaging – ultrasound or CT

     

    4. Common question-specific information required
    In addition to above information in #3

    • AKI and electrolyte disturbances
      • Baseline Cr/eGFR, timeline and current Cr/eGFR
      • Key investigations + treatment (eg CT abdo pelvis … on IV antibiotics)
      • Medication list (including pre-admission medications)
      • Nephrotoxins – common: contrast, NSAIDs, ACEI/ARB, antibiotics
      • Urine Na (spot) useful if suspecting cardiorenal or hepatorenal syndrome
    • Peritoneal dialysis patients
      • PD exchange frequency and concentration (eg 4x/day, 1.5% bags)
      • Any issues with drainage of PD, cloudy bags, pain or exit site infection
    • Haemodialysis patients
      • Access (line, graft, fistula), days of dialysis (eg mon/wed/fri)
      • Any issues with dialysis (eg missed sessions, bleeding, blocked AVF)
    • Preeclampsia:
      • Gravidity and Parity, if imminent delivery
      • Past history of pregnancy complications, hypertension, pre/eclampsia
      • Urine analysis (and follow up PCR), liver function tests, full blood count
      • Complications in previous pregnancy, PHx (hypertension), medications

     

    5. Background Medical History relevant to consults to this Specialty (e.g. previous contact with specialist, letters)
    • Renal history
      • Cause of kidney disease and whether had renal biopsy (eg IgA nephropathy)
      • Specific treatment of kidney disease (eg prednisone or immunosuppression)
      • If on dialysis, baseline eGFR, proteinuria, hematuria
      • Other issues: previous stones, recurrent UTIs, medications’
    • Major comorbidities and systemic illness
      • Metabolic disease (hypertension, diabetes)
      • Auto-immune disease (vasculitis, SLE etc.)
      • Cardiac disease, liver disease

     

    6. Family/social history relevant to consults to this Specialty
  • History of renal disease
  •  

    7. Medications relevant to consultations to this Specialty
    • PLEASE HAVE COMPLETE LIST OF MEDICATIONS FOR CONSULT
    • ACEi/ARB, diuretics, NSAIDs & other analgesics
    • Metformin (risk lactic acidosis in renal failure/eGFR < 30), PPI, antibiotics
    • ESA (e.g. Aranesp), phosphate binders
    • Over the counter/herbal medications

     

    8. Investigations relevant to consultations to this Specialty
    Depends on reason for consult: baseline investigations should include potassium, bicarbonate, creatinine, eGFR, calcium, phosphate, albumin, urine analysis (UA), renal tract imaging (current or previous)

     

    9. Essential Investigations required for specific consults
    • AKI: K, HCO3, Ur, Cr, eGFR, Ca, PO4, Hb, UA (if protein +, sent for PCR, if blood +, send for microscopy to look for dysmorphic cells). Renal tract imaging (discuss with registrar) – bedside bladder scan useful as initial check for retention.
    • Hyponatraemia: serum and urine Na & osmolality, TFTs, early morning cortisol
    • Hyperkalaemia: HCO3, K, Cr, ECG (if K >6.0 mmol/L)
    • Hypercalcemia: Ca, Mg, PO4, PTH, Vit D, EPG/iEPG/SFLC

     

    10. Investigations relevant to consultations to this Specialty (and why)
    • Urinalysis, as screen for UTI, proteinuria and glomerularnephritis
    • Renal tract imaging – to exclude a post-renal cause of AKI, size (clue for chronicity)

     

    11. Extra tips for acquiring consults
    • Try to formulate a question or a request - if unsure, ask your registrar (e.g. “We would like your opinions regarding this patient’s acute kidney injury”)
    • Have the medication chart and observation chart with you

    Respiratory and Sleep Medicine

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

     

    2. General clinical information/questions relevant to consults to this Specialty
    o Essential
    • Presence of dyspnoea/wheeze/cough/sputum production/haemoptysis/chest pain/oedema/fever
    • Physical examination: Oxygen saturations, respiratory rate, temperature, GCS, raised JVP, wheeze, crepitations, bronchial breathing, peripheral oedema
    • Relevant history of respiratory disease (COPD, lung fibrosis, bronchiectasis, pulmonary hypertension, lung cancer, etc)
    o Helpful
    • Prior need for intubation or non-invasive ventilation
    • Current cognition compared to baseline and ability to make decisions

     

    3. Common question-specific information required
    o 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
    o If suspected PE: prior VTE, current and prior anticoagulation, Wells’ criteria, haemodynamic stability, contraindications to anticoagulation, history of COPD/renal failure
    o If suspected pneumonia or COPD exacerbation: productive cough, fevers, number of exacerbations, prior resistant organisms (eg-pseudomonas), risk factors for aspiration
    o If abnormal lung radiology: changes compared to last imaging, is imaging on Cerner or via outside radiology
    o ?Need bronchoscopy: recent chest imaging (recent CT chest/HRCT chest), previous procedures (bronchoscopy, induced sputum, sputum culture, pleural procedure), sedative risk (eg current spirometry, ABG), coagulation status (renal impairment, thrombocytopaenia, aspirin, clopidogrel, clexane, warfarin, rivaroxaban ... etc)
    o 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, warfarin, rivaroxaban ... etc)

     

    4. Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc)
    o 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?
    o Helpful
    • Prior known respiratory specialist, letters and investigations (including CT chest, PFT, TTE)
    • Functional status
    • Exercise tolerance

     

    5. Family/social history relevant to consults to this Specialty
    o Essential
    • Smoking history (including second-hand smoke)
    • Occupational History
    • Asbestos exposure
    • Living situation (nursing home or at home)
    o Helpful
    • Pets, bird exposure, unusual hobbies

     

    6. Medications relevant to consultations to this Specialty
    o Steroids
    o Diuretics
    o Bronchodilators
    o Antibiotics
    o Immunosuppressives
    o Anticoagulation(includingprophylactic)

     

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

     

    8. Essential Investigations required for specific consults
    o Shortnessofbreath:spirometry,ABG,chestX-ray,baselinebloods
    o Increasedoxygenrequirement:ABG,spirometry,chestX-ray,baselinebloods including FBC, UEC, LFT, CRP o SuspectedPE:ChestX-ray,ABG
    o Suspectedortreatmentofpneumonia:ABG,chestX-ray,baselinebloodsincluding FBC, UEC, LFT, CRP
    o Abnormalchestradiology:priorimagingmustbechased,aswellaspriorbiopsiesif applicable
    o Sleep disorders: ABG if significant obstructive sleep apnoea suspected or BMI >40kg/m2
    o ?Needforbronchoscopy:spirometry,ABG,coagulationprofile,platelet,CXR,recent imaging with either CT chest or HRCT chest
    o ManagementofPleuralEffusion:CXRwithin24hoursofconsult,coagulationprofile, platelet count

     

    9. Investigations relevant to consultations to this Specialty (and why)
    o Spirometry (to confirm or exclude obstructive or restrictive defect)
    o Arterial Blood Gas (to confirm level of hypoxaemia, assess for hypercapnia, and assess metabolic compensation)
    o Chest X-ray (to diagnose pulmonary pathologies)

     

    10. Common problems in calls for consults
    o Old information not obtained (eg long standing radiological changes not requiring further investigation)
    o No imaging obtained prior to consult
    o No recent spirometry and ABG performed
    o Consultation for consideration of pleural aspirate/drain insertion, but with the most recent CXR performed 3-4 days prior to the consultation

     

    Rheumatology

    1. Mechanism for requesting a consult
    • Please page rheumatology advanced trainee on #27244

     

    2. Common questions/reasons for consults to this Specialty
    • Gout
    • Could this be rheumatological?
    • Known arthritis
    • Managing DMARDs
    • PUO

     

    3. General clinical information/questions relevant to consults to this Specialty
    Essential
    • The rheumatological question
    • Background of the patient, past history of gout/arthritis
    • If gout - have they had a needle aspirate before? Which joints were involved in the past?
    • Evidence for arthritis, how many joints, are they swollen, red, hot?
    • Any associated features of a connective tissue disease
    • Any temperatures
    Helpful
    • Can they walk, how disabled are they? If they have seen a rheumatologist, who was this rheumatologist?

     

    4. Common question-specific information required
    • Joint aspirate results if performed this time or previously
    • Results of autoimmune serology
    • ESR and CRP

     

    5. Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc)
    Essential
    • Any rheumatological review in the past, with whom?
    • Family history
    • Renal, respiratory or cardiac issues
    Helpful
    • Letters from past specialists/information from GPs

     

    6. Medications relevant to consultations to this Specialty
    • Any DMARDs
    • Allopurinol/colchicine
    • Biologics if on

     

    7. Investigations relevant to consultations to this Specialty
    • Serum urate
    • AI serology (ANA, ENA, ds-DNA, RhF, Anti-ccp, ANCA)
    • CRP, ESR, Hb, Platelets, WCC
    • C3 and C4, Urinalysis
    • Imaging

     

    8. Essential Investigations required for specific consults
    • If ?rheumatological, AI serology often helpful If swollen or painful joint, needs an X-ray and urate level

     

    9. Investigations relevant to consultations to this Specialty
    • X-rays (often not done) AI serology Urinalysis (relevant, often not done, needs MC&S, Casts, Dysmorphic cells)

     

    10. Common problems in calls for consults Often limited information about background, x-rays usually not done, common AI screen not known
    Often no complete medication history related to arthritis from the past.

     

    Dec 2016

     

    Toxicology


    1. Mechanism for requesting a consult
    o Contact Switchboard for first on call Tox team member

     

    2. Common questions/reasons for consults to this Specialty
    o Paracetamol overdose
    o Digoxin & lithium toxicity
    o Serotonin syndrome & NMS
    o Anticholinergic delirium

     

    3. General clinical information/questions relevant to consults to this Specialty
    o Essential
    • Exposure: Agent/drug, time, dose, route
    • Revevant drug levels
    • Renal and liver function tests
    • ECG
    • Regular medication list o Helpful
    • Neurological exam (tone, reflexes, clonus)

     

    4. Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc)
    o Essential
    • Medication list
    • Adverse drug reactions/allergies
    • Methadone/buprenorphine dose confirmed
    o Helpful
    • Renal and liver function test results

     

    5. Family/social history relevant to consults to this Specialty
    o Essential
    Drugs available at the home

     

    6. Medications relevant to consultations to this Specialty
    o Analgesics
    o Over-the-counter medication & Herbal/traditional medicines &
    o Cardiac & psychotropic drugs

     

    7. Essential Investigations required for specific consults
    o Specific drug levels
    o ECG–cardiac drugs,psychotropics,analgesics
    o βHCG–women of child-bearing age
    o Snakebite:fibrinogen,coagulation profile,D-Dimer,CK

     

    8. Investigations relevant to consultations to this Specialty
    o Venous blood gas
    o ECG
    o Drug levels

     


    May 2017

    Transplant Surgery

    1.Mechanism for requesting a consult
    o Contact transplant registrar or fellow through switch either via pager or mobile phone.

     

    2. Common questions/reasons for consults to this Specialty
    o Peritoneal Dialysis Access
    o Vas Cath Insertion
    o Transplanted patient admitted under another team’s care

     

    3. General clinical information/questions relevant to consults to this Specialty
    o Essential
    • Succinct summary of current problems.
    • Past surgical history?
    • Taking anticoagulants?
    • Electrolytes, Renal Function, Hb?
    • Urgency of need for dialysis access (be specific)
    • On Immunosuppressants?
    o Helpful
    • Are the relevant renal team involved? Who?
    • Current dialysis method and plan.

     

    4. Common question-specific information required
    o Recent bloods
    o Vas Cath: ?known problems with R and L IJVs
    o Peritoneal Access: any hernias?
    o General medical suitability for surgery, if relevant.

     

    5. Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc)
    o Essential
    • Known to which surgical consultant?
    • Date of transplant, if relevant
    • Reason for renal failure, if relevant
    o Helpful
    Any relevant clinic letters

     

    6. Family/social history relevant to consults to this Specialty
    o Essential
    • Inpatient / Outpatient with respect to timing for dialysis access

     

    7. Medications relevant to consultations to this Specialty
    o Any anticoagulants
    o Immunosuppressants/steroids

     

    8. Investigations relevant to consultations to this Specialty
    o Recent Bloods
    o Relevant Imaging

     

    9. Essential Investigations required for specific consults
    o EGFR/Creatinine/Electrolytes in renal failure
    o Vein mapping if requires fistula formation

     

    10. Investigations relevant to consultations to this Specialty (and why)
    Bloods (as above)

     

    11. Common problems in calls for consults
    Please consult us EARLY when patients who are transplanted and immunosuppressed present with surgically-relevant problems

     

    12. Extra tips for acquiring consults
    If cannot get through to pager, call registrar on mobile phone via switch. If that doesn’t work, we are probably operating or sleeping and you should contact our intern / resident for advice on our availability.

     

    Trauma

    1. Mechanism for requesting a consult
    o Page the Trauma Registrar #8969

     

    2. Common questions/reasons for consults to this Specialty
    o To clear cervical spine
    o To manage rib fractures

     

    3. General clinical information/questions relevant to consults to this Specialty
    o Essential
      I - dentifiers
      M - echanism of injury
      I - njuries suspected
      S – igns and symptoms (Primary Survey ABCDE)
      T – reatment provided
      A – llergies
      M – edications
      P – ast medical history
      L – ast oral intake (time)
      E – vents up to date

     

    4. Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc)
    o Essential
    • Co-morbidities
    • Previous discharge summaries

     

    5. Family/social history relevant to consults to this Specialty
    o Essential
    • Family support / next of kin info / support network upon potential discharge
    • Smoking / alcohol / recreational drug history

     

    6. Medications relevant to consultations to this Specialty
    Anti-coagulants

     

    7. Investigations relevant to consultations to this Specialty
    Primary survey X-rays, FAST, CT

     

    8. Essential Investigations required for specific consults
    Imaging of all suspected injuries

     

    9. Investigations relevant to consultations to this Specialty (and why)
    CT – most sensitive and specific investigation for injuries

     

    10. Common problems in calls for consults
    Delayed consult with inadequate workup of patients

     

    11. Extra tips for acquiring consults
    Being clear and concise by formulating a logical/valid question which can be answered, thereby making the consult worthwhile.

     

    Upper GI Surgery

    1. Mechanism for requesting a consult
    o Contact the UGI registrar consult pager, which is 27745

     

    2. Common questions/reasons for consults to this Specialty
    o UGI consults
    o Gallbladder pathology
    o Feeding tubes
    o UGI malignancies/lesions (eg oesophageal, pancreatic etc)

     

    3. General clinical information/questions relevant to consults to this Specialty
    o Essential
    • Demographics
    • Reason for consult (!)
    • Previous surgical history (important)
    • Functional status, quality of life
    • Medical comorbidities
    o Helpful
    • Copy of operation reports
    • Known to surgeons?
    • Investigations so far
    •What specific question do you have for the team? Eg take over care, advise on management

     

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

     

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

     

    6. Family/social history relevant to consults to this Specialty
    o Essential
    • Premorbid function
    • Does patient/family want an operation
    • Is the patient/family aware of the consult/reason for the consult

     

    7. Medications relevant to consultations to this Specialty
    o Anticoagulants
    o Antiplatelet medications
    o Immunosuppression
    o Chemotherapy

     

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

     

    9. Essential Investigations required for specific consults
    o LFTs and INR (for liver problems)
    o Tumour markers (for cancers)
    o 3phase CT may be appropriate (ask)

     

    10. Investigations relevant to consultations to this Specialty
    o 3 phase CT
    o MRI/MRCP
    o Tumour markers
    o LFTs and INR
    o Hepatitis screen (HBVSAg, HCV Ab)

     

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

     


    Jun 2017

    Urology

    1. Mechanism for requesting a consult
    o Contact via Urology Consults Page #27557

     

    2. Common questions/reasons for consults to this Specialty
    o RenalColic
    o Haematuria
    o Fourniersgangrene
    o Scrotal Pain

     

    3. General clinical information/questions relevant to consults to this Specialty
    o Essential
    • History and examination findings
    • Haematuria
    • Lower urinary tract symptoms
    • Renal function
    • Comorbidities
    • Presence of sepsis
    o Helpful
    • CTKUB
    • Urinary MCS, cytology

     

    4. Common question-specific information required o Renalstone:size,location,symptoms,
    o Renalfunction,
    o Presenceofsepsis
    o Haematuria–clots,retention,colour;history of benign prostatic hyperplasia, cancer, radiation, anticoagulants
    o Fourniers–immunocompromised,DM,alcohol,obesity,known genitourinary/GIT pathology, tenderness, crepitus, numbness
    o Scrotal pain–age,history,previous pain,urinary symptoms,sexual history

     

    5. 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

     

    6. Medications relevant to consultations to this Specialty
    o Anticoagulants
    o Antiplatelet medications
    o Immunosuppression
    o Steroids
    o Nephrotoxicmedications

     

    7. Investigations relevant to consultations to this Specialty
    o MSU
    o Urinecytology
    o CTKUB or CT3phase
    o Renal function

     

    8. Essential Investigations required for specific consults
    o Haematuria–MSU, Upper tract imaging, cytology
    o Stones–CTKUB,Renal function, Urinalysis/MSU
    o Fourniers - FBC,CRP,coagulation studies +/- CT if in doubt

     

    9. Investigations relevant to consultations to this Specialty
    o Renalfunction
    o MSU
    o CT

     

    Vascular Surgery

    1. Mechanism for requesting a consult
    o Introduction: who is the person calling
    o Situation: presenting complaint
    o Background: history leading to presenting complaint
    o Assessment: summary and diagnosis if possible
    o Request: emergency/elective/admission

     

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

     

    3. General clinical information/questions relevant to consults to this Specialty
    o Essential
    • Duration symptoms
    • Previous interventions
    • Is limb/life at immediate risk
    o Helpful
    • Presentation acute or chronic

     

    4. Background Medical History relevant to consults to this Specialty (e.g. previous contact with Specialty, letters, reports, o/s travel, etc)
    o Essential
    • Diabetes
    • Renal Function
    • Hypertension
    • IHD
    • Hypercholesterolaemia
    o Helpful
    • Previous arterial interventions (open and endovascular)
    • Previous contrast reaction

     

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

     

    6. Medications relevant to consultations to this Specialty
    o Warfarin/heparin/novel anticoagulation
    o Anti-platelets
    o Metformin

     

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

     

    8. Essential Investigations required for specific consults
    o investigations will be directed by the vascular team as appropriate for the presenting problem

     

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

     

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

     

    Nov 2017

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