"Non-sults"

[neurologist]

You know: those "consults" that are just ridiculous.

Post your favorites here.

Today I got a clinic patient with note from primary MD: "patient's migraines not responding to current meds and she is dizzy and off balance."

Ummmm, maybe that's because 5 mg of Klonpin isn't a "migraine medication"?

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[bustbones26]

You know: those "consults" that are just ridiculous.

Post your favorites here.

Today I got a clinic patient with note from primary MD: "patient's migraines not responding to current meds and she is dizzy and off balance."

Ummmm, maybe that's because 5 mg of Klonpin isn't a "migraine medication"?

If I had a nickle for every miscalled TIA, well, I would not be posting here because I'd be exceptionally wealthy and not practicing medicine anymore.

Typically, Non-sults are a way of dumping difficult patients onto a neurologist.

 

[danielmd06]

If I had a nickle for every miscalled TIA, well, I would not be posting here because I'd be exceptionally wealthy and not practicing medicine anymore.

I second the "TIA" consult.

During residency, that was a generic consult term for absolutely any neurologic complaint. My personal favorite of all these was "dizziness." Those ER consults never failed to give me this heart-sinking feeling (they also seemed to have the nasty habit of getting called about 20 minutes before the on-call resident was supposed to take over).

By the end of residency, I had taken to joking with the ED guys about the diagnosis of what I termed "vague dizziness" (appropriately abbreviated as "VD"), and had even told them I was going to complete a fellowship in dizziness (or rather, autonomic disorders as it were).

 

[AlternateSome1]

To give this more "credibility", our ED will write, "dizziness - cannot exclude vertebrobasilar insufficiency, consult neurology."

 

[bustbones26]

I second the "TIA" consult.

During residency, that was a generic consult term for absolutely any neurologic complaint. My personal favorite of all these was "dizziness." Those ER consults never failed to give me this heart-sinking feeling (they also seemed to have the nasty habit of getting called about 20 minutes before the on-call resident was supposed to take over).

By the end of residency, I had taken to joking with the ED guys about the diagnosis of what I termed "vague dizziness" (appropriately abbreviated as "VD"), and had even told them I was going to complete a fellowship in dizziness (or rather, autonomic disorders as it were).

We had an acronym too, TeNDS

Transient Neurological Deficit of Dubious Significance.

 

[bustbones26]

To give this more "credibility", our ED will write, "dizziness - cannot exclude vertebrobasilar insufficiency, consult neurology."

I did a military residency, so every friday night, every single 20 something in the ED with a "stroke"?? Hey guys, its Friday night on a military base, did you check and blood alcohol level?

 

[neglect]

Typically, Non-sults are a way of dumping difficult patients onto a neurologist.

Or, even worse, of ordering a history.

 

[Mattchiavelli]

Or, even worse, of ordering a history.

this

"pt had syncope" ---> patient had coughing fit and passed out at the end for lack of oxygen

"r.o seizure" ---> cousin Raydean said grandma had a seizure because she was falling asleep and jerked a little (hypnic jerk)

"Headache referral" ---> "do you get headaches?" "sometimes, I just take tylenol and they're fine"

"patient is sleepy all the time... Narcolepsy?" ----> patient is taking a fistfuls of opiates daily and their neck is the size of a virginia ham

I do like the aspect of our specialty being pretty history-heavy, however I don't like when people assume that means they can leave it to us because the second any neurologic buzzword came up it's instant referral

 

[Telamir]

Seizure consult--> 86 year old man was taken to the toilet to poop, he pushed, passed out.

 

[clement]

I'm willing to bet psych has just as many or more nonsults;
Like anyone with a psych med in their list that has been medically cleared
and needs to be dispo'ed (autocorrect: disposed) = "looks anxious and sad." yeah so does everyone who has been sitting around in ED waiting area.

 

[neurolddoc]

The best is the patient with the referral written out by the primary's secretary "Neurology consult for kidney stone"

 

[bustbones26]

The best is the patient with the referral written out by the primary's secretary "Neurology consult for kidney stone"

I agree. I see a lot of misplaced "UROLOGY" consults. Sadly, patients seem pissed whenever office staff calls them up and attempts to problem.

 

[maddog2020]

I agree. I see a lot of misplaced "UROLOGY" consults. Sadly, patients seem pissed whenever office staff calls them up and attempts to problem.

"pissed" off - that is great !!

 

[Acherona]

HPI: 55 y/o hispanic female complaining of dizziness and diffuse pain with pan-positive review of systems. poor historian.
Exam: vocalizing "ayayayayay", otherwise nonfocal
Summary: There's an "ayayay" with full-body dolor in the ED
Workup: panscan

 

[neurodoc]

I really appreciate some of the consult requests I get from my psychiatry colleagues. Here are a few, verbatim:

1) "23 yo male with schizoaffective disorder, on Risperdal Consta. Has tremor, psychomotor ******ation, and balance problems. Please evaluate and manage for Parkinson's Disease." When examined, the patient had a Parkinsonian tremor, bradykinesia, and cogwheeling. He was not prescribed any EPS meds like Cogentin or Artane. No FHx of PD. I suggested a trial of anti-EPS meds in addition to the Risperdal. The Psychiatrist expressed some surprise at this, remarking that EPS is not a problem with atypical antipsychotics....or so he was told by the drug company reps who extolled the benefits of their proprietary atypical antipsychotics. Duh!

2) "43 yo male with severe psychotic depression, not responsive to medications and very confused and agitated." On exam it turned out that the patient had asterixis, elevated AST/ALT, and low (2.8) albumin. and frontal release signs (snout and palmomental reflexes). Brain MRI showed frontotemporal atrophy (probably due to old head trauma). He was HCV+ on serology tests. His symtoms improved with a lactulose Rx.

3) "36 yo paranoid schizophrenic with abnormal orofacial movements and tardive dyskinesia. Please evaluate and make recommendations." It turned out that this patient had caudate atrophy evident on MRI. Genetic testing confirmed a diagnosis of Huntington Disease.

 

[michaelrack]

I really appreciate some of the consult requests I get from my psychiatry colleagues. Here are a few, verbatim:

1) "23 yo male with schizoaffective disorder, on Risperdal Consta. Has tremor, psychomotor ******ation, and balance problems. Please evaluate and manage for Parkinson's Disease." When examined, the patient had a Parkinsonian tremor, bradykinesia, and cogwheeling. He was not prescribed any EPS meds like Cogentin or Artane. No FHx of PD. I suggested a trial of anti-EPS meds in addition to the Risperdal. The Psychiatrist expressed some surprise at this, remarking that EPS is not a problem with atypical antipsychotics....or so he was told by the drug company reps who extolled the benefits of their proprietary atypical antipsychotics. Duh!

2) "43 yo male with severe psychotic depression, not responsive to medications and very confused and agitated." On exam it turned out that the patient had asterixis, elevated AST/ALT, and low (2.8) albumin. and frontal release signs (snout and palmomental reflexes). Brain MRI showed frontotemporal atrophy (probably due to old head trauma). He was HCV+ on serology tests. His symtoms improved with a lactulose Rx.

3) "36 yo paranoid schizophrenic with abnormal orofacial movements and tardive dyskinesia. Please evaluate and make recommendations." It turned out that this patient had caudate atrophy evident on MRI. Genetic testing confirmed a diagnosis of Huntington Disease.

#3 sounds like a reasonable consult. #2 IM should have been consulted instead. Agree that #1 is a stupid consult.

 

[neurodoc]

#3 sounds like a reasonable consult. #2 IM should have been consulted instead. Agree that #1 is a stupid consult.

You are right. I was quite happy to be asked to see that patient and make the correct diagnosis. It wasn't really that difficult. On review of his extensive record going back more than a decade, even before he was first seen by Psychiatry for vague behavioral problems (impulsivityand mood swings, and eventually frank paranoid psychosis). There were comments in his chart about abnormal movements before he was prescribed psych meds. When I saw him he looked like a guy with HD or some other choreiform disorder, but the clincher was that he had prominent involuntary facial movements (eyebrow raising, grimacing, jaw thrusting, etc) along with spontaneous choreic upper extremity jerking followed by attempts to "correct" these movements by morphing their terminal components into meaningful movements (such as sweeping a hand across his hair or rubbing his nose). These things are not typical of TD, but are very common in HD.

Anyhow, that's what he had. Were it a generalist who referred the patient I'd have no concerns. However, it was a Psychiatrist, who I expect would have been a bit more discerning. And that was just the latest of many Psychiatrists who'd been seeing him for about 8 years. Psychiatrist are certified by our Board, the ABPN. They are expected to have competency in Neurology. Maybe not so much as Neurologists, but certainly more than Internists and FPs.

Maybe this should prompt a discussion about the general medical competence of Psychiatrists, who after all are licensed Physicians. They make this point whenever Psychologists seek the authority to provide aspects of mental health care currently provided by Psychiatrists (including prescribing psychotropics).

This argument (Psychiatrists are physicians and Psychologists are not) loses force whenever Psychiatrists are unable or unwilling to manage basic medical problems in their patients, especially problems that are directly related to the medications that they prescribe (e.g.: metabolic syndrome, constipation, extrapyramidal side effects, hypothyroidism, bone marrow suppression, hepatitis, NMS, etc. Not to mention the fact that Psychiatrists are supposed to have special expertise in determining whether or not "psychiatric symptoms" are due to primary Psychiatric illness or are secondary to some other "organic" (i.e. medicalor neurologic disorder.😳

 

[michaelrack]

Maybe this should prompt a discussion about the general medical competence of Psychiatrists, who after all are licensed Physicians. They make this point whenever Psychologists seek the authority to provide aspects of mental health care currently provided by Psychiatrists (including prescribing psychotropics).

This argument (Psychiatrists are physicians and Psychologists are not) loses force whenever Psychiatrists are unable or unwilling to manage basic medical problems in their patients, especially problems that are directly related to the medications that they prescribe (e.g.: metabolic syndrome, constipation, extrapyramidal side effects, hypothyroidism, bone marrow suppression, hepatitis, NMS, etc. Not to mention the fact that Psychiatrists are supposed to have special expertise in determining whether or not "psychiatric symptoms" are due to primary Psychiatric illness or are secondary to some other "organic" (i.e. medicalor neurologic disorder.😳

You'll get no arguement from me. As someone who is certified in both Psych/IM (as well as several subspecialties), I am willing to throw my psych colleagues under the bus when appropriate.

One appropriate consult (I think) is when a psychiatrist refers a patient to a neurologist to cover themselves and make sure the patient is aware of the risks of continuing treatment- signs of early TD on a anti-psychotic or mild tics in a patient on stimulants (who has failed alternative treatment). In this case I do think that the psychiatrist should "own" the problem and should just be getting confirmation or 2nd opinion.

Of course, I am in private practice so my consults are usually welcomed. I can understand why neuro residents get upset about unreasonable consults.

 

[neurodoc]

I agree on all points, though I really don't want to overly criticize my Psych colleagues and definitely don't relish the idea of throwing any of them "under the bus"...though I sometimes wonder if that's exactly what they are trying to do (i.e. shift liability to another physician) when they ask me to "manage" a patient with some side effect of their prescriptions (TD, Parkinsonism, dystonia, metabolic syndrome, CBC abnormalities, hyponatremia (from Tegretol/Trileptal), etc. I've been out of residency for many years now, but I work in a state hospital. Fortunately, I serve as a Medical/Neurological consultant within this system. I do my best to provide my Psychiatric colleagues with very good advice, but I'm also careful not to let my colleagues "disown" their patients.🙂

...One appropriate consult (I think) is when a psychiatrist refers a patient to a neurologist to cover themselves and make sure the patient is aware of the risks of continuing treatment- signs of early TD on a anti-psychotic or mild tics in a patient on stimulants (who has failed alternative treatment). In this case I do think that the psychiatrist should "own" the problem and should just be getting confirmation or 2nd opinion.

Of course, I am in private practice so my consults are usually welcomed. I can understand why neuro residents get upset about unreasonable consults.

 

[danielmd06]

I agree. I see a lot of misplaced "UROLOGY" consults. Sadly, patients seem pissed whenever office staff calls them up and attempts to problem.

Holy cow I forgot all those pages for "Nephrology," "Urology," or "Neurosurgery." And 99% of the urology ones were at 2AM for me to come put a foley back in someone or for hematuria. Good times.

Then the stroke pager would go off again...for another TIA in the ED.

 

[michaelrack]

I don't throw psychiatrists under the bus in real life; I just meant that I am willing to criticize psychiatrists in general and the profession on the internet, when warranted.

 

[typhoonegator]

I don't throw psychiatrists under the bus in real life

...because that would be homicide.

 

[Mattchiavelli]

*page page* Yes? *blah blah* "when are you taking this person to surgery?" "well, I'm not taking anyone to surgery, ever, because I'm a Neurologist"

I try to come up with new ways of differentiating myself from Urology whenever that gets messed up

Brains, not balls
Pons, not prostate
Seizures, not semen
etc

I have a new non-sult... Patient just had a cath earlier today, consult is for left leg weakness specifically foot drop, acute onset. Bilateral femoral arteries were used, as patient had significant atherosclerotic plaques and first access site had to be abandoned. Acute painful onset of loss of function, especially painful in foot. On exam, left leg is painful, pallid, pulseless, poikilothermic....

also from a friend on call, from the children's hospital we cover
"this patient is a 4 year old that had a febrile seizure before... she has a UTI now and hasn't had a seizure or one since, but we just wanted neurology to see them"

 

[bustbones26]

Best I ever had:

Back whenever I was reviewing outpatient consults for military neurology clinic, consult: "knee pain"???

I refused, replied back, "what about the knee pain is neurological?"

A few weeks go by, reconsult, "knee pain". I ask the same question? No reply
Next thing you know, patient is storming patient advocacy office stating that her primary care physican told her that I am outright refusing to see her.

BTW, in the military, most primary care physicians are PA-C or NPs. No, that is not PA-C or NPs under direct supervision, that IS YOUR Primary care physician, given virtually all rights of a fully board certified family medicine doctor. Anyways, I walk the patient into the clinic and ask her only one question and the conversation went something like this:

ME: when did the knee pain start?
PATIENT: Back in July
ME: Did you go to sick call at your primary clinic?
PATIENT: Yes
ME: What did they do?
PATIENT: Nothing
ME: Okay. (pull up electronic chart back from July and see a note for the family medicine clinic with primary diagnosis of Partial thickness burn. Open up note, documented that patient burned the skin over her knee with a curling iron)

Um, okay (to patient) I think we are done here!

Next one,

PA-C from clinic. Patient is having a bad headache and had a car accident two days ago, I want to make sure that they are not having hemorrhage!!!

ME: Um, look, if you really think that is the case, why not send them to the ER, like, right now!!! I mean, I am on call and will have to see them anyways, and they will get a stat head CT if you call over there ahead of time and talk to the ER docs.

PA-C: (rudely), So you are refusing to see the patient?

ME: No, just saying that if you are honestly worried about hemorrhage, what am I going to do in my clinic? I would send them to the ER, because I can't do a head CT in my clinic. (admit that I was a bit rude and sarcastic back).

PA-C: Fine!!

A month later, called to colonel's office to explain why I so rude to a subordinate PA-C??


In the first case, that NP was eventually fired for continuing to perform mess ups.

In the second case, that PA-C is unfortunately going to kill somebody

I am glad I no longer have to put up with that crap!!

 

[soulofmpatel]

Some of my nonsults. I was not directly involved in some of these cases

1) called for slurred speech in elderly woman. Further history reveals cough and runny nose X 1 day; denies speech complaints. Exam benign except for hoarse voice; Dx: URI

2) Called for weakness of the L leg and severe pain after fall. Exam reveals obvious deformity of the left proximal thigh. X ray reveals L hip fracture

3) Called for confusion in liver transplant pt. Exam is nonfocal jaundiced obtunded pt. laboratory evaluation reveals t bili > 10 and other LFT abnormalities (baseline normal)

4) appointment for fatigue after running for greater than 4 hours (pt was a competitive long distance runner). Exam benign. Attending diagnosed "endotoxemia" and prescribed Co Q10 (not necessarily a nonsult-but not really in the field of neurology).

 

[soulofmpatel]

also from a friend on call, from the children's hospital we cover
"this patient is a 4 year old that had a febrile seizure before... she has a UTI now and hasn't had a seizure or one since, but we just wanted neurology to see them"

haha. ...and people wonder why health care costs are so high.

 

[AlternateSome1]

Early in the morning when finishing an overnight shift as a resident, I was called to the trauma bay for an "acute stroke" due to new onset facial droop. I get to see the patient and there was clear swelling of the lip and tongue, and an ACE-I was started a few days earlier. I let the ED attending know what I was seeing, what my suspicion was, and that I didn't need neuroimaging. The response: "How can you be sure it isn't a stroke?"

 

[soulofmpatel]

Early in the morning when finishing an overnight shift as a resident, I was called to the trauma bay for an "acute stroke" due to new onset facial droop. I get to see the patient and there was clear swelling of the lip and tongue, and an ACE-I was started a few days earlier. I let the ED attending know what I was seeing, what my suspicion was, and that I didn't need neuroimaging. The response: "How can you be sure it isn't a stroke?"

Haha.

You reminded me of a case a resident at another program described to me.

He was called for slurred speech, and he sees the patient who is floridly drunk and has no deficits except for slurring of words due to intoxication.

The resident goes to the ER attending and has the following conversation:

Resident: "This patient is drunk!"
ER physician: "Well...I can't rule out a stroke"
Resident: "You can't rule out a stroke on me!"

 

[BlackFrancis33]

To satisfy your internal passive aggressivist, you can always sarcastically explain in excruciating and unnecessary detail what EtOH does to the Nervous System, where the deficits localize in the CNS and so on.

 

[95439]

whoops

 

[807crash]

Actually, it is quite rough with patients who are drunk or have psych overlay. In residency, I knew of one psych patient who became completely paralyzed because he was difficult and a consult was delayed and assumed to be inappropriate. Myself, I saw a drunk patient (r/o stroke) who was very hard to examine and I made the mistake of not bringing in the MRI tech at 3am to image his neck (after a fall) when it turned out he had a mild (and then evolving) central cord injury.

I guess my point is.... you never know.

We used to say in our hospital that probably every patient in the hospital would benefit from a neurology consult. When you thought about it, it often was true! Certainly no other specialty does as good H&Ps.

Of course, I was very tired during residency....

 

[soulofmpatel]

Actually, it is quite rough with patients who are drunk or have psych overlay. In residency, I knew of one psych patient who became completely paralyzed because he was difficult and a consult was delayed and assumed to be inappropriate. Myself, I saw a drunk patient (r/o stroke) who was very hard to examine and I made the mistake of not bringing in the MRI tech at 3am to image his neck (after a fall) when it turned out he had a mild (and then evolving) central cord injury.

I guess my point is.... you never know.

We used to say in our hospital that probably every patient in the hospital would benefit from a neurology consult. When you thought about it, it often was true! Certainly no other specialty does as good H&Ps.

Of course, I was very tired during residency....

You make a valid point crash. I heard of a case where a drunk young woman in her twenties presented with slurred speech and was initially blown off but then progressed to a locked in state in front of the eyes of a tele-stroke-neurologist who recommended an intervention (I can't remember if it was IV tPA or thrombectomy) which resulted in complete improvement.

I've had my fair share of unexpected diagnoses in seemingly unnecessary consults.

 

[bustbones26]

You make a valid point crash. I heard of a case where a drunk young woman in her twenties presented with slurred speech and was initially blown off but then progressed to a locked in state in front of the eyes of a tele-stroke-neurologist who recommended an intervention (I can't remember if it was IV tPA or thrombectomy) which resulted in complete improvement.

I've had my fair share of unexpected diagnoses in seemingly unnecessary consults.

We once gave a patient hell become he drove himself to the hospital while having a stroke. He later explained that he was at a public park and whenever he had his stroke, he was trying to beg every bystander for help, but they all shrugged him off as a public drunk.

I think the real complaint here is that many of the ER docs do not examine the patients. As the patient is rolling of the ambulance, they are on the phone calling neuro with something "neurological" without a basic exam (albeit not by a skilled neurologist), labs, basic imaging, etc. I always knew whenever an IM resident was rotating through the ER because I was given a clear and concise history of present illness.

Now before you all think that I am bashing on the ER docs, there are some good ones out there. Unforunately, I feel that ER docs are now trained to "triage and call" and I have fully noted this since ER residency has transitioned to a 3 year program minus a transitional year internship.