Inpatient Consults

How to approach a consult:

Having a systematic way to approach diagnoses can be helpful. Here’s one such approach:

  • On your first day, ask your resident to share the consult patient list with you in Epic. If you have time, you can always view the list from home to see if any new patients have been added to the list from overnight.
  • Always start by looking at the photographs uploaded by the primary team in the Media tab and the patient’s vital signs. If there is any concern about an unstable patient, discuss with your resident about seeing them on the sooner side. 
  • Read up on the patient in Epic, including past medical/derm history and relevant medications. It is generally most helpful to read notes from other consultants and the most recent primary team progress note. Additionally, it is very helpful to search for prior derm consult or clinic notes. For a new admission, start with the H&P. 
  • Start a consult note using your resident’s template to help you synthesize the patient’s history into a coherent story.  If you work on the note prior, more will stick with you when you go see and present the patient later!
  • Brainstorm a differential based on available photos and the history you gathered from pre-charting. VisualDx, UpToDate, and your resident may be helpful with this.
  • See the patient, clarify the timeline, ask appropriate questions to narrow down your differential, inquire about prior derm history, describe the rash (including location, symptoms, spread). 
  • Take photos using Haiku to upload to the chart. 
  • If relevant, make sure to review the patient’s labs, microbiology data, imaging, and pathology. 

Presentation:

  • One liner/reason for consult: This is the MOST important part of your presentation (other than the A/P) as it is what you lead with. A great one-liner should include the patient’s demographics (age/gender), relevant PMHx (do not need to include every medical problem the patient has, just those relevant to the admission and/or reason for consult), reason for admission, any notable events in hospital course, and finally the reason for the consult. 
    • Here is an example of a quality one-liner: “Mr. Y is a 54-year-old male with a new diagnosis of AML (dx 4/2020), admitted for 7+3 induction chemotherapy with cytarabine and daunorubicin (day 1 = 5/12/20). His course has been complicated by neutropenic fevers x 5 days and a presumed fungal pneumonia for which he is on itraconazole. Dermatology was consulted for a new painful rash over the face and upper extremities.”
  • HPI: Focused on the rash/skin lesion. Remember to get a timeline, as well as cutaneous and systemic symptoms. 
  • Past Derm History: History of hospitalizations for derm conditions? Skin biopsies? Skin cancers? (only if relevant)
  • PMH: Focused, only if relevant to CC
  • Meds: Focused on relevant attempted treatments, or those that cause drug reactions. Worth noting immunosuppressants.
  • Allergies, FH, and SH: Only if relevant 
  • Labs: CBC, LFTs, anything relevant to CC, monitor trends
  • Other data: Relevant imaging, microbiology,  pathology results 
  • Vitals: Generally skipped in derm; mention only if relevant (e.g. febrile in setting of infection rule out)
  • Physical Exam: Skin type, describe findings (see “Morphology” in Content section), location of lesions
  • A/P: Provide a broad differential with supportive/non-supportive data/findings for each diagnosis. Remember to provide pertinent negatives along with pertinent positives.  Make an attempt at outlining a plan with regards to confirming diagnosis, if needed, and initiating treatment.
  • Tips: Consider practicing with your consult resident. They are there to help you succeed and are happy to hear your presentation and provide feedback before rounds. Presentations should be high yield and concise, generally limited to ~5-6 minutes for a complex patient, ~2-4 minutes for a straightforward consult. 

Consult Note:

  • It is helpful to ask your consult resident for his/her templates, as well as feedback on notes you have written.
  • Here is a link to a template you may use.
  • Include photos you took while you did the PE. The PE consists of describing lesions/rashes. See “Morphology” in Content section” section to learn terminology on this.
  • Your consult resident is always available to help with additional questions.