Ward

How to do a consult

Why were you called, what is the question, and the note that answers it. The flow is the same on every ward; the two consults below, one adult and one pediatric, show it in both domains.

01
Why were you called?
Read the request, then phone the referrer: the written question and the real question often differ.
02
What is the question?
Turn it into one answerable sentence. 'Please see' is not a question; 'is this hyponatremia safe to operate through?' is.
03
History
Take your own history; the referring team's version is a starting point, not a substitute.
04
Examination
Examine for the question and for what the referring team might have missed.
05
Data
Chart review with trends: the numbers before admission, the medication chart, the fluids, the last three days.
06
Problem representation
One sentence: who, what, tempo, the discriminating features.
07
Differential
Most likely, must not miss, other; committed, not listed.
08
Assessment
Your answer to the question, with the reasoning that supports it.
09
Plan
Specific, actionable, owned: who does what by when, and what would change it.
10
Present to the senior
The question, the one sentence, your answer, your plan. Ninety seconds.

The request

Medical consult requested by general surgery: '68F, sodium 121, please advise. Booked for laparotomy tomorrow.'

On the phone

The surgical resident: 'Her sodium was 128 on admission two days ago, now 121. She has been on dextrose-saline at 125 an hour since she came in nil by mouth. She is a bit drowsy today. We want to know if we can operate.'

The patient

68-year-old woman admitted with a sigmoid mass and subacute obstruction, nil by mouth for 48 hours, on hypotonic maintenance fluids, with a thiazide on her home list and a sodium falling from 128 to 121. Drowsy but rousable, no seizure.

Chart review

Sodium 128 (admission), 125 (day 1), 121 (today). Potassium 3.4. Urea 3.1. Glucose 6.2.
Fluids: 0.18 percent saline with 4 percent dextrose at 125 mL/hour for 48 hours.
Medications: bendroflumethiazide 2.5 mg (home), regular oxycodone since admission, ondansetron.
Examination: euvolemic to mildly dry, JVP not raised, no edema, GCS 14 (confused speech).
Urine osmolality 480, urine sodium 62 (sent this morning by the nurse on a hunch).
Nausea and pain documented; vomited twice yesterday.

01 · Reason for consult
State the question you are answering, as the surgeons would recognize it.
02 · History
The history that discriminates the cause: fluids, drugs, losses, symptoms.
03 · Examination
Volume status and neurology, the two examinations that decide this consult.
04 · Investigations
The trend and the urine studies, interpreted.
05 · Assessment
Your answer: mechanism, severity, and fitness for surgery.
06 · Plan
Specific and owned: what changes now, the correction target, the monitoring, and what would change the plan.