Consults- Memorable/Dismal/Ridiculous/Unique

[Winged Scapula]

Equally depressing corollary, when you’re called to evaluate a patient who has already expired, but nobody noticed yet. Happened more than once at our inner city site.

Yep, had one of those in residency.

I was the 3rd year on Colorectal and got paged to see a consult in the MICU with "abdominal distention". I'm between cases so I tell the Chief that I'll head up to see it; he follows about 5 minutes later and finds me sitting at the desk charting in the MICU.

C: "What's up. Acute abdomen?"
M: Well he's non-tender although pretty distended.
C: Any imaging?
M: No, but I don't think we need any.
C: Really? That bad? Ok, should we book him?
M: No.
C: No?
M: No...he's dead.
C: Dead?
M: Yeah, I walked in...he's non responsive, asytolic. Ya know. Dead.
C: Okay, nothing to do here, et's go have lunch! (j/k...we didn't have lunch. He made me finish the note and call the consulting service to thank the for the "most interesting consult").

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[HighPriest]

Yep, had one of those in residency.

I was the 3rd year on Colorectal and got paged to see a consult in the MICU with "abdominal distention". I'm between cases so I tell the Chief that I'll head up to see it; he follows about 5 minutes later and finds me sitting at the desk charting in the MICU.

C: "What's up. Acute abdomen?"
M: Well he's non-tender although pretty distended.
C: Any imaging?
M: No, but I don't think we need any.
C: Really? That bad? Ok, should we book him?
M: No.
C: No?
M: No...he's dead.
C: Dead?
M: Yeah, I walked in...he's non responsive, asytolic. Ya know. Dead.
C: Okay, nothing to do here, et's go have lunch! (j/k...we didn't have lunch. He made me finish the note and call the consulting service to thank the for the "most interesting consult").

So. What was wrong with his abdomen? The family wants their money’s worth.

 

[Winged Scapula]

So. What was wrong with his abdomen? The family wants their money’s worth.

He smelled like dead gut.

Which reminds me, once you smell that, you never forget it.

I had a new patient consult in the office Thursday, sent right away from her primary care. I smelled her the minute I walked in. She and her daughter professed to me their concern that she had an infection due to the "smell".

I held my tongue until I examined her but the rotting flesh from which the smell emanated confirmed my olfactory diagnosis when I entered the door that she had a necrotic fungating mass on her breast. I just don't know how people can live like that.

 

[dpmd]

He smelled like dead gut.

Which reminds me, once you smell that, you never forget it.

I had a new patient consult in the office Thursday, sent right away from her primary care. I smelled her the minute I walked in. She and her daughter professed to me their concern that she had an infection due to the "smell".

I held my tongue until I examined her but the rotting flesh from which the smell emanated confirmed my olfactory diagnosis when I entered the door that she had a necrotic fumigating mass on her breast. I just don't know how people can live like that.

Denial is powerful. Plus back to my earlier comment, dying tissue hurts but dead tissue doesn't. She probably thought she was getting better.

 

[Winged Scapula]

Denial is powerful. Plus back to my earlier comment, dying tissue hurts but dead tissue doesn't. She probably thought she was getting better.

Yep. Easy biopsy- didn't need any local, just a scalpel.

I think the only reason she went to her primary was because of the smell and bleeding which made her think she had an infection.

 

[HighPriest]

Oropharyngeal cancer is the same way. I don’t think I’m exaggerating to say that at least 60-70% of the time I know the biopsy will be positive just based on the smell.

 

[Apollyon]

Denial is powerful.

Or tachyphylaxis. Had a kid with a draining butt abscess, and I asked, "What about the smell?", and he said, "What smell?"

 

[HighPriest]

Had a guy come in stating that about 5 years ago he was exposed to mold, and when that happened it destroyed his immune system and lowered all of the energy levels in his body, and now everything is wrong. GI upset, plugged ears, stuffy nose, swollen throat, and a list of problems so long that I can't include them all. He brought me three plastic water bottles full of his own mucus that he had collected, so that he could show me that if he left them to sit for a long enough time they would grow mold, which indicated to him that his body was infested with mold. He said when he was first exposed, he didn't have bowel movement for three months.

 

[OrthoTraumaMD]

Yep, had one of those in residency.

I was the 3rd year on Colorectal and got paged to see a consult in the MICU with "abdominal distention". I'm between cases so I tell the Chief that I'll head up to see it; he follows about 5 minutes later and finds me sitting at the desk charting in the MICU.

C: "What's up. Acute abdomen?"
M: Well he's non-tender although pretty distended.
C: Any imaging?
M: No, but I don't think we need any.
C: Really? That bad? Ok, should we book him?
M: No.
C: No?
M: No...he's dead.
C: Dead?
M: Yeah, I walked in...he's non responsive, asytolic. Ya know. Dead.
C: Okay, nothing to do here, et's go have lunch! (j/k...we didn't have lunch. He made me finish the note and call the consulting service to thank the for the "most interesting consult").

In residency when I was a chief, I knew a patient had died during the night. It was early in the morning, before 5am, and the nurses forgot to put a “do not enter” sign on the door. My junior resident walked in there before I could stop her to round on the patient. I waited until she came out and said, “leg looks good, patient’s sleeping so I didn’t want to wake her.”


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[HighPriest]

In residency when I was a chief, I knew a patient had died during the night. It was early in the morning, before 5am, and the nurses forgot to put a “do not enter” sign on the door. My junior resident walked in there before I could stop her to round on the patient. I waited until she came out and said, “leg looks good, patient’s sleeping so I didn’t want to wake her.”


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I assume you made her go back in and check a distal pulse?

 

[OrthoTraumaMD]

I assume you made her go back in and check a distal pulse?

Lol nah I had like 30 others to round on and I’m like “dude she’s dead.”


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[Psai]

In residency when I was a chief, I knew a patient had died during the night. It was early in the morning, before 5am, and the nurses forgot to put a “do not enter” sign on the door. My junior resident walked in there before I could stop her to round on the patient. I waited until she came out and said, “leg looks good, patient’s sleeping so I didn’t want to wake her.”

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There is a fracture. I fixed it.

 

[deleted547339]

Had a guy come in stating that about 5 years ago he was exposed to mold, and when that happened it destroyed his immune system and lowered all of the energy levels in his body, and now everything is wrong. GI upset, plugged ears, stuffy nose, swollen throat, and a list of problems so long that I can't include them all. He brought me three plastic water bottles full of his own mucus that he had collected, so that he could show me that if he left them to sit for a long enough time they would grow mold, which indicated to him that his body was infested with mold. He said when he was first exposed, he didn't have bowel movement for three months.

Ever seen someone with Morgellon’s syndrome? That’s fun...

 

[HighPriest]

Ever seen someone with Morgellon’s syndrome? That’s fun...

If by that you mean delusional parasitosis: yes. Unnervingly frequently. Lots of patients come in because there are worms, bugs, etc., that they think crawl in to their ears or noses when people try to identify them. Had a guy demand that my partner cut his ear open because the worms under his skin were crawling in there to hide from his doctors.

 

[Chillbo Baggins]

In residency when I was a chief, I knew a patient had died during the night. It was early in the morning, before 5am, and the nurses forgot to put a “do not enter” sign on the door. My junior resident walked in there before I could stop her to round on the patient. I waited until she came out and said, “leg looks good, patient’s sleeping so I didn’t want to wake her.”


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Day 3 of residency I'm on call and rounding on half the trauma list, people I've never seen, and I get to this room and the patient is non responsive. I'm doing sternal rubs and not feeling any pulse and starting to panic because this patient looks super dead but I dunno if I still need to call a code. As I'm internally debating, the nurse comes in and goes, "Yeah, the family made them DNR last night and they passed about an hour ago." And I just go, "Oh thank God!"

I text my attending about it and add that we're not primary and he goes, "Thank God!"

 

[Apollyon]

Lol nah I had like 30 others to round on and I’m like “dude she’s dead.”


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There is a fracture. I fixed it.

Did you post her to the OR?

(I meant to post this WEEKS ago.)

 

[OrthoTraumaMD]

Did you post her to the OR?

(I meant to post this WEEKS ago.)

No, we had fixed her earlier.


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[Crabbygas]

When I was a medicine intern and had an inpatient die I would be sure to book them for a couple of follow up visits in clinic. Because our clinic sucked and a sure fire no-show was always welcomed.

 

[Winged Scapula]

When I was a medicine intern and had an inpatient die I would be sure to book them for a couple of follow up visits in clinic. Because our clinic sucked and a sure fire no-show was always welcomed.

Ha! That's a fabulous idea (except for the fact that the family would get a call reminding them of the appointment which sort of sucks).

 

[vhawk]

Ha! That's a fabulous idea (except for the fact that the family would get a call reminding them of the appointment which sort of sucks).

Lesson learned early in practice, hell hath no fury like a recent widow who gets a phone call reminder about her husbands follow up appt

 

[Psai]

Lesson learned early in practice, hell hath no fury like a recent widow who gets a phone call reminder about her husbands follow up appt

Oncology?

 

[VincentAdultman]

When I was a medicine intern and had an inpatient die I would be sure to book them for a couple of follow up visits in clinic. Because our clinic sucked and a sure fire no-show was always welcomed.

Man that’s dark... but pretty brilliant.

 

[VA Hopeful Dr]

Lesson learned early in practice, hell hath no fury like a recent widow who gets a phone call reminder about her husbands follow up appt

The office I worked for to get experience for med school would comb the obituaries every day and run the names against the patient list to make sure that never happened.

 

[Jolie South]

Got a consult for a pseudoaneurysm of femoral artery by cards from access....okay

Look into it more and they were doing a carotid angio on a guy with 99% stenosis bilaterally. Asymptomatic. Somehow we are not involved until a day after they cause the PSA.

Run into the fellow later and he is like “yea, we should have stented that”.

WTF. How about you leave the management of carotid disease to vascular then we don’t have groin problems and carotid problems?

 

[swoopyswoop]

Got consulted for a bruise at a lovenox injection site from the ER at 10 pm.

 

[HighPriest]

Got consulted for a bruise at a lovenox injection site from the ER at 10 pm.

You ever see one of those things open up? It’s like a can of worms. Blood everywhere. Lovenox injection sites are the carotid blowout of needle sticks.

 

[startswithb]

ED nurse calls me at midnight to ask "where we keep the foley leg bag connectors." Almost died.

 

[swoopyswoop]

You ever see one of those things open up? It’s like a can of worms. Blood everywhere. Lovenox injection sites are the carotid blowout of needle sticks.

Yea, I declined to open it at the bedside. Very small hematoma. No evidence of infection whatsoever. The PA consulted convinced it was an abscess despite zero evidence supporting that diagnosis, and did not bother to walk about the corner to consult the 6 ER physicians in-house before consulting us from home. I think I will require an MD-to-MD conversation in the future for consults like this...

 

[HighPriest]

Yea, I declined to open it at the bedside. Very small hematoma. No evidence of infection whatsoever. The PA consulted convinced it was an abscess despite zero evidence supporting that diagnosis, and did not bother to walk about the corner to consult the 6 ER physicians in-house before consulting us from home. I think I will require an MD-to-MD conversation in the future for consults like this...

I don't even remember if I mentioned it on this thread in the past (I probably did). I was consulted one time for a "neck abscess close to the carotid." When I saw the patient, it was literally an 1cm follicular abscess under his chin. I had to pull the ER resident in to the room to make sure we were talking about the same thing. I mean, I guess, relative to something like a pilonidal this was close to the carotid...It was already draining, by the way. I told them to put him on antibiotics if they wanted. They asked me when he should follow up with me, and I told them "when he has an ENT problem."

 

[Pir8DeacDoc]

Yea, I declined to open it at the bedside. Very small hematoma. No evidence of infection whatsoever. The PA consulted convinced it was an abscess despite zero evidence supporting that diagnosis, and did not bother to walk about the corner to consult the 6 ER physicians in-house before consulting us from home. I think I will require an MD-to-MD conversation in the future for consults like this...

It boggles my mind why they call a consult before discussing the case with the supervising MD.

I got called last week by a PA in the ER. Pt has very sore throat for two days. Didn't know if you wanted to come see her or if I should get a scan. Umm. Any vitals? Any wbc count? Any exam? I said "what does your supervising doc think?" She hadn't even discussed it with him. Geez. Come on lady

 

[smq123]

It boggles my mind why they call a consult before discussing the case with the supervising MD.

I got called last week by a PA in the ER. Pt has very sore throat for two days. Didn't know if you wanted to come see her or if I should get a scan. Umm. Any vitals? Any wbc count? Any exam? I said "what does your supervising doc think?" She hadn't even discussed it with him. Geez. Come on lady

Not just not discussing the case with the supervising physician, it's amazing that they didn't even do a basic exam and workup.

As a resident, if I did anything major (order a CT, call in a consult, send to the ER) without doing a significant exam/history, the attending would have (rightfully) ripped me a new one.

I supervised a PA who once casually mentioned that he was on the phone with EMS, to transport a patient with a BP of 185/110. When I asked how the patient looked, if he was suspecting a stroke, how did the EKG look, did they need an aspirin, etc., he said, "Oh, I don't know. I haven't even seen the patient yet." I told him that if he EVER called EMS again without at least spending 3 minutes evaluating the patient in person, I would personally make sure that he had to work every single Saturday for the next 4 months straight. Harsh, maybe, but it got the point across.

 

[HighPriest]

It boggles my mind why they call a consult before discussing the case with the supervising MD.

I got called last week by a PA in the ER. Pt has very sore throat for two days. Didn't know if you wanted to come see her or if I should get a scan. Umm. Any vitals? Any wbc count? Any exam? I said "what does your supervising doc think?" She hadn't even discussed it with him. Geez. Come on lady

This isn't very uncommon at all. In fact, I generally assume that PAs haven't spoken with anyone when they call me. Maybe there's left over from the military where they were not only expected to run completely solo, but they were encouraged not to bother the docs.

Nothing makes me happier than getting a call in a busy clinic, getting the ER nurse station first, being put on hold for 5 minutes, then getting a PA who immediately apologizes for "bothering you during a busy clinic day," but at the exact same time they can't answer a single question about the patient without putting me back on hold and going to check...

 

[HighPriest]

Had a funny one over the weekend. Technically a patient call rather than a consult, but still made me laugh.

8 year old patient's mother called. He's got one of those made-up names that suburban soccer Moms give their kids so that they can feel unique. Also, he had just come back from soccer practice. He wears hearing aids. Mom says he took one out when he got home and there was some orange stuff on it. No blood, no pain, no hearing loss. She thinks he ruptured his ear drum. No pain either. Wasn't sure why she thought that, and then she says he can't hear out of that ear anymore. So I said "is this the first time you've seen this orange stuff?" She says "yes." The kid says "no." (Turns out I'm on speaker phone). She says "How long has it been going on?" (because 8 year olds are excellent judges of time) and he says "Since I was five." She says "No it hasn't." He says "Yes it has." She says "No it hasn't, when did it start?" He says "Since I was 7..." And I'm sitting here listening to this riveting conversation. So I interrupt and ask "Sorry, and this is going to sound like a dumb question but: If he puts the hearing aid back in, how is his hearing?" And she asks him to do it, and he says "It's fine." She says "I guess it's fine."

So, in theory, they'll see me today so I can clean his orange ear wax. I felt like an IT guy. "Have you checked to make sure the computer is plugged in?"

 

[Jolie South]

A couple of consults for “slurred speech concerning for stroke” this week.

1st guy just had loose dentures.

2nd guy had alcohol level of 200. Miraculously slurred speech resolved once alcohol wore off.

 

[smq123]

A couple of consults for “slurred speech concerning for stroke” this week.

1st guy just had loose dentures.

2nd guy had alcohol level of 200. Miraculously slurred speech resolved once alcohol wore off.

 

[TeddyBoomBoom]

Had a funny one over the weekend. Technically a patient call rather than a consult, but still made me laugh.

8 year old patient's mother called. He's got one of those made-up names that suburban soccer Moms give their kids so that they can feel unique. Also, he had just come back from soccer practice. He wears hearing aids. Mom says he took one out when he got home and there was some orange stuff on it. No blood, no pain, no hearing loss. She thinks he ruptured his ear drum. No pain either. Wasn't sure why she thought that, and then she says he can't hear out of that ear anymore. So I said "is this the first time you've seen this orange stuff?" She says "yes." The kid says "no." (Turns out I'm on speaker phone). She says "How long has it been going on?" (because 8 year olds are excellent judges of time) and he says "Since I was five." She says "No it hasn't." He says "Yes it has." She says "No it hasn't, when did it start?" He says "Since I was 7..." And I'm sitting here listening to this riveting conversation. So I interrupt and ask "Sorry, and this is going to sound like a dumb question but: If he puts the hearing aid back in, how is his hearing?" And she asks him to do it, and he says "It's fine." She says "I guess it's fine."

So, in theory, they'll see me today so I can clean his orange ear wax. I felt like an IT guy. "Have you checked to make sure the computer is plugged in?"

F-ing awesome....

 

[VincentAdultman]

Yeah NPs and PAs calling consults without discussing with the ED attending I thought was pretty typical.

 

[akwho]

Yeah NPs and PAs calling consults without discussing with the ED attending I thought was pretty typical.

This shouldn't be allowed in my opinion... At a bare minimum they should have a 30 second discussion with the ED attending to make sure they agree with the consult.

 

[dpmd]

This shouldn't be allowed in my opinion... At a bare minimum they should have a 30 second discussion with the ED attending to make sure they agree with the consult.

One of the surgeons who used to take call basically forbade any midlevel from calling a consult without staffing it first with an attending. I think they have quit adhering to that though. Luckily I don't get too many stupid calls from them (either because the patients who end up needing a surgeon aren't seen by them as often or because they don't suck as much as others do)

 

[deleted547339]

Yeah NPs and PAs calling consults without discussing with the ED attending I thought was pretty typical.

This makes me thankful to work where I work.....our midlevels function like good interns, some good pgy2s. I’ve never had them call a consult I thought was inappropriate, and the number of times I’ve had them call a consult without talking to me is minimal and usually a chip shot (e.g. calling gen surg when concern for appy has positive CT, calling OB for PUL follow up, calling neuro for MS flair sent from home by neuro to be admitted, etc).

 

[VincentAdultman]

This makes me thankful to work where I work.....our midlevels function like good interns, some good pgy2s. I’ve never had them call a consult I thought was inappropriate, and the number of times I’ve had them call a consult without talking to me is minimal and usually a chip shot (e.g. calling gen surg when concern for appy has positive CT, calling OB for PUL follow up, calling neuro for MS flair sent from home by neuro to be admitted, etc).

Lol I had a mid level call me about osteo in the great toe and miss all the telltale signs clinically and radiographically of necrotizing fasciitis so sadly that has not been my experience.

 

[HighPriest]

Got a consult for postnasal drip and sinusitis. The patient's symptoms were dysarthria and slowing speech with word finding difficulty that has been rapidly worsening over the last 6 months. His PCP told him it was postnasal drip, diagnosed him with dysphonia, and treated him with flonase for 3 months until he referred him to me.

 

[wholeheartedly]

Got a consult for postnasal drip and sinusitis. The patient's symptoms were dysarthria and slowing speech with word finding difficulty that has been rapidly worsening over the last 6 months. His PCP told him it was postnasal drip, diagnosed him with dysphonia, and treated him with flonase for 3 months until he referred him to me.

 

[Raryn]

Got a consult for postnasal drip and sinusitis. The patient's symptoms were dysarthria and slowing speech with word finding difficulty that has been rapidly worsening over the last 6 months. His PCP told him it was postnasal drip, diagnosed him with dysphonia, and treated him with flonase for 3 months until he referred him to me.

Please tell me that PCP wasn't a physician

 

[TraumaLlamaMD]

Please tell me that PCP wasn't a physician

Right? Like he was high on PCP maybe and hallucinated this was real medical advice?

 

[HighPriest]

Please tell me that PCP wasn't a physician

It was indeed. Now, I will say that the patient was calling his symptoms "hoarseness, or a change in voice" but if you actually ask him to describe what he's experiencing it was dysarthria, slowing speech, and word finding difficulty. So I have no doubt the PCP heard hoarseness and said "Ok, here's some flonase, now GTFO." But, that's also how you miss a progressing neurologic condition. Patient histories. That's why you spend 4 years learning how to take them.

The fact is the patient didn't know what hoarseness was. Which seems surprising, but it's not his job to know that.

If only all patients came in and said "hey, doc, I think I have psuedobulbar palsy," and you could just rely on that. Boy, that'd make things easier. Almost like you wouldn't need doctors at all.

My favorite part was when the patient said "I don't think I have postnasal drip," and I said "Me either, buddy. Me either."

 

[VisionaryTics]

Got a consult for postnasal drip and sinusitis. The patient's symptoms were dysarthria and slowing speech with word finding difficulty that has been rapidly worsening over the last 6 months. His PCP told him it was postnasal drip, diagnosed him with dysphonia, and treated him with flonase for 3 months until he referred him to me.

I got a consult once for a patient being mute. I was like "that's not an ENT problem, if he's not speaking, it's a neurology problem". They said he was just sitting there with his mouth open, fully conscious, but wouldn't talk.

I go and see the patient and he's got bilateral TMJ subluxations. I pop him back into place in front of his family, the primary doctor, and nurses and he immediately starts talking. He had been in the hospital for 4 days getting a million dollar workup including MRI, carotid dopplers, CT scans, psych consult.

 

[HighPriest]

I got a consult once for a patient being mute. I was like "that's not an ENT problem, if he's not speaking, it's a neurology problem". They said he was just sitting there with his mouth open, fully conscious, but wouldn't talk.

I go and see the patient and he's got bilateral TMJ subluxations. I pop him back into place in front of his family, the primary doctor, and nurses and he immediately starts talking. He had been in the hospital for 4 days getting a million dollar workup including MRI, carotid dopplers, CT scans, psych consult.

Wonderful.

 

[Apollyon]

I got a consult once for a patient being mute. I was like "that's not an ENT problem, if he's not speaking, it's a neurology problem". They said he was just sitting there with his mouth open, fully conscious, but wouldn't talk.

I go and see the patient and he's got bilateral TMJ subluxations. I pop him back into place in front of his family, the primary doctor, and nurses and he immediately starts talking. He had been in the hospital for 4 days getting a million dollar workup including MRI, carotid dopplers, CT scans, psych consult.

Hey, it WAS an ENT problem, then!

 

[310prolene]

I got a consult once for a patient being mute. I was like "that's not an ENT problem, if he's not speaking, it's a neurology problem". They said he was just sitting there with his mouth open, fully conscious, but wouldn't talk.

I go and see the patient and he's got bilateral TMJ subluxations. I pop him back into place in front of his family, the primary doctor, and nurses and he immediately starts talking. He had been in the hospital for 4 days getting a million dollar workup including MRI, carotid dopplers, CT scans, psych consult.

None of the CTs or MRIs over the 4 days showed the TMJ subluxation?