Hilariously Terrible Neuro Consults Thread

Started by deleted496821
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deleted496821

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Given burnout in Neuro is reaching very high levels, in no small part because of the ridiculousness of many of our consults, this thread is needed for a laugh if anyone is to have longevity in this specialty. Please only post real consults.

- "Is this just an MS flare?" in a woman with "end-stage" MS only able to lift her RUE antigravity at baseline and otherwise 2/5 elsewhere in extremities, with "confusion" at home and obtundation in the ED with BP 60/40

- Stroke code for a man with 1 week of constipation that had transient lightheadedness when he finally had his much needed huge BM
 
"S/p aortic valve replacement with intermittent transient L arm incoordination when trying to put in hearing aid. Stroke?"

"Outpatient recommend ED eval for 'electrical sensations in brain.'"

"Bradycardic/apneic events...seizure?"
 
There are a lot of funny stories that would fit here, but the most persistently enraging feature is when someone else just wants you to do their history and physical. Most often seen from surgeons on the floor that want to be able to just read your note for dictation, and NPs in the ED who just automatically consult someone based on the triage note so they can copy/paste your history and exam.

That said, I still laugh at the time I was called for a TIA consult for someone whose arm had just fallen asleep after they had slept on it funny.
 
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I was called in the late evening for possible meningitis. I told the resident that I had no clue why she was even thinking about meningitis, but she told me that her attending (and chair of medicine at the hospital) was concerned. So I came in. The patient was sleeping comfortably and when I woke him (or her or xie), he was normal, just confused as to why he ANYONE would want to place a needle in his back. He was in the hospital for abdominal pain, was alert and conversant, had no headache. I checked the name and room number to make sure I wasn't missing the person with a fever and headache and lethargy, even checked my list, checked with the nurse, then said sorry for waking you up. To this day I have no clue.

I've seen MANY stupid consults, but that one remains baffling. I called the resident, who doubled down and blamed her attending.

As an outpatient, things are even worse. Once had a 46 year old patient with a + blood test (want to stay vague) ordered by NP, and saw a specialist in rheum/ID/endo who called me and told me that not only was the blood test NOT even positive (was misread), but the patient had had to wait 4 months for the appointment, AND even IF +, then it wouldn't explain progressive speech/swallow weakness. Saw patient, diagnosed ALS.

Things are even worse now that patients have access to their reports and notes. They bring in their normal MRIs with the normal white matter changes and ddx circled, highlighted, and googled.

But remain calm everyone, never blame the patients.
 
@neglect I've noticed a significant difference when it comes to MRI scan interpretation between a hospitalist and a neurologist. Almost every time in the notes the hospitalist concurs with the interpretation from the radiologist (literal c/p of impression), even though very little is stated in the impression. Some things to note is that I haven't seen a hospitalist really comment on making an attempt at presentation etiology when it comes to a stroke e.g. thrombotic v. embolic? Watershed? Hemorrhagic or hemorrhagic conversion? Big difference in a lot of the work up that also follows from that initial interpretation when it comes down to the MRI e.g. MRI revealed hypoperfusion in area of the brain which was initially interpreted as a stroke, but the likely etiology was due to something else entirely due to patient's prior medical history.
 
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after p3 said:
@neglect I've noticed a significant difference when it comes to MRI scan interpretation between a hospitalist and a neurologist. Almost every time in the notes the hospitalist concurs with the interpretation from the radiologist (literal c/p of impression), even though very little is stated in the impression. Some things to note is that I haven't seen a hospitalist really comment on making an attempt at presentation etiology when it comes to a stroke e.g. thrombotic v. embolic? Watershed? Hemorrhagic or hemorrhagic conversion? Big difference in a lot of the work up that also follows from that initial interpretation when it comes down to the MRI e.g. MRI revealed hypoperfusion in area of the brain which was initially interpreted as a stroke, but the likely etiology was due to something else entirely due to patient's prior medical history.
Click to expand...

Do u really expect a hospitalist to read an mri properly?
 
neglect said:
I was called in the late evening for possible meningitis. I told the resident that I had no clue why she was even thinking about meningitis, but she told me that her attending (and chair of medicine at the hospital) was concerned. So I came in. The patient was sleeping comfortably and when I woke him (or her or xie), he was normal, just confused as to why he ANYONE would want to place a needle in his back. He was in the hospital for abdominal pain, was alert and conversant, had no headache. I checked the name and room number to make sure I wasn't missing the person with a fever and headache and lethargy, even checked my list, checked with the nurse, then said sorry for waking you up. To this day I have no clue.
Click to expand...
It is funny you even went there. I would ask to obtain CSF, consider empiric antibiotics and call me back when results are ready. Evaluation for meningitis/encephalitis is totally within ER/IM expertise, in majority of cases neurology is not even needed and if needed, just to tailor the treatment, but obviously not to come at night to do a lumbar puncture. It is not a consultation, it is "come and do my work for me", if you allow to do this, it becomes a habit.
 
Not a consult, but (very common)...
Patient: "All my doctors say I have MS (Lyme disease). All my symptoms are textbook MS symptoms!"
Stupid neurologist: "Well, however, you don't have any lesions on your brain MRI and MRI of your entire spine. Your neurological exam is completely normal as well. Your CSF showed 0 oligoclonal bands. I would say your symptoms, neurological exam, MRI and CSF are not quite typical for MS"
Patient: "But all my doctors say they are! They think I have MS and I read a lot about it!"
Stupid neurologist: "Who are those doctors?"
Patient: "My primary care doctor, my cardiology and my rheumatology".
 
Last edited:
after p3 said:
@neglect I've noticed a significant difference when it comes to MRI scan interpretation between a hospitalist and a neurologist. Almost every time in the notes the hospitalist concurs with the interpretation from the radiologist (literal c/p of impression), even though very little is stated in the impression. Some things to note is that I haven't seen a hospitalist really comment on making an attempt at presentation etiology when it comes to a stroke e.g. thrombotic v. embolic? Watershed? Hemorrhagic or hemorrhagic conversion? Big difference in a lot of the work up that also follows from that initial interpretation when it comes down to the MRI e.g. MRI revealed hypoperfusion in area of the brain which was initially interpreted as a stroke, but the likely etiology was due to something else entirely due to patient's prior medical history.
Click to expand...
I know zero hospitalists who try to interpret MRIs (and I'm married to a good one). They trust the radiologists read or show it to a specialist. Not in their scope of practice at all not should it be.
 
Thama said:
I know zero hospitalists who try to interpret MRIs (and I'm married to a good one). They trust the radiologists read or show it to a specialist. Not in their scope of practice at all not should it be.
Click to expand...
I had no idea. This explains a lot, thank you.
 
Amen, I’m not a neuroradiologist and I’m not going to ever try to overread one on my own. Nor am I a neurologist or neurosurgeon. If the radiologist says “could be nothing could be brain tumor/stroke/hemorrhage...” I’m finding a brain tumor/stroke/hemorrhage expert to advise, otherwise I am a reckless dumb****. Knowing one’s limitations is a crucial part of responsible practice, if you don’t want to be Dr. Dunning Kruger MD.
 
Algor said:
Not a consult, but (very common)...
Patient: "All my doctors say I have MS (Lyme disease). All my symptoms are textbook MS symptoms!"
Stupid neurologist: "Well, however, you don't have any lesions on your brain MRI and MRI of your entire spine. Your neurological exam is completely normal as well. Your CSF showed 0 oligoclonal bands. I would say your symptoms, neurological exam, MRI and CSF are not quite typical for MS"
Patient: "But all my doctors say they are! They think I have MS and I read a lot about it!"
Stupid neurologist: "Who are those doctors?"
Patient: "My primary care doctor, my cardiology and my rheumatology".
Click to expand...
I’m a lowly PGY neuro resident. Could you explain why you think the response by the neurologist in this example you gave “stupid”?
 
It’s not actually stupid, but the patient may feel that it is if they don’t understand your reasoning OR if they are unshakably, pathologically convinced (or induced by secondary gain to claim) that they must have neuro condition X despite all the evidence you reasonably explain to them.
 
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Algor said:
Not a consult, but (very common)...
Patient: "All my doctors say I have MS (Lyme disease). All my symptoms are textbook MS symptoms!"
Stupid neurologist: "Well, however, you don't have any lesions on your brain MRI and MRI of your entire spine. Your neurological exam is completely normal as well. Your CSF showed 0 oligoclonal bands. I would say your symptoms, neurological exam, MRI and CSF are not quite typical for MS"
Patient: "But all my doctors say they are! They think I have MS and I read a lot about it!"
Stupid neurologist: "Who are those doctors?"
Patient: "My primary care doctor, my cardiology and my rheumatology".
Click to expand...


HA! Literally had this conversation once, "So you have Lyme disease, presenting with highly atypical clinical history from the usual rash, arthritis/algia, and cardiac problems, instead having chronic fatigue. You had no evidence of Lyme in your blood, despite multiple testing, except one band at one time. You have seen many different ID doctors who all told you that you don't have Lyme, except one, who said you did and promised you'd get better if you did what he said and got IV antibiotics. You then had 6 months of multiple antibiotic rounds, which you paid for, with no change in symptoms. Do you think we should consider if you have or don't have Lyme?"

"Why? I know I have Lyme. [I'm here about my other conversion/malingering symptoms]"

I'm the stupid neurologist.
 
Too many to count.

Probably my worst was getting called in to the hospital by a GP to turn off a bladder stimulator. “I thought that’s what you do.” I didn't go in.

At my old job I would get called in to do lumbar punctures.
 
Freeinfinity said:
I'll bite. "The patient is desating when we change his position or the pressure settings on the vent. Could this be a seizure?"
Click to expand...

Now this is what I'm talking about. It is consults like these that make me afraid for the average patient at the average hospital. Did you as the Neurologist diagnose the 3 L pleural effusion for them via Ultrasound and do the thoracentesis for the ICU team as well?
 
FoodLovinMD said:
Now this is what I'm talking about. It is consults like these that make me afraid for the average patient at the average hospital. Did you as the Neurologist diagnose the 3 L pleural effusion for them via Ultrasound and do the thoracentesis for the ICU team as well?
Click to expand...

Lol, I got another one. ED consulted me for altered mental status. The patient literally had papers from an outside hospital that he brought with him. The ED physician didn't take a look at it yet. I review the records and it shows he's got transaminitis and was being treated for hepatic encephalopathy at the outside hospital. My exam significant for asterixis. I tell them to check an ammonia and liver enzymes. Everything came back elevated. Voila. Diagnosed.
 
Stroke alert! Facial droop and glucose of 30! On arrival patient has peripheral 7th. States he's had a Bell's for 2 years.
 
For those I like to show the classic Josephson video of convulsive syncope.

It was the #1 hit on my service when I was a senior resident and I had medicine juniors. "this is why you dont call effing neurology for every effing twitch when the cause is otherwise obviously cardiogenic you effing dumbeff"
 
- 62 year old homeless man found down in the bathroom at <local fast food joint> and now intermittently responding to providers. New onset absence seizures?

- Got called for "XX year old man with new penis deviation. Please evaluate for neuro causes." Went to see the patient, and was told that starting that week, only half his penis was becoming tumescent. He told me that, as a consequence, his penis was deviating to the opposite side. His significant other (at bedside) chimed in enthusiastically with "Hell yeah it is!"
 
Asklepian said:
- Got called for "XX year old man with new penis deviation. Please evaluate for neuro causes." Went to see the patient, and was told that starting that week, only half his penis was becoming tumescent. He told me that, as a consequence, his penis was deviating to the opposite side. His significant other (at bedside) chimed in enthusiastically with "Hell yeah it is!"
Click to expand...

The charitable part of me wants to think they meant to call urology, not neurology. The less charitable part of me wants whoever called that consult to be stuck in a hellscape of whatever is the most annoying and inappropriate consult imaginable in their specialty, forever, without hope of escape.
 
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