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eConsult Orders Available Now

Allergy and Immunology

Sample Questions

  • 48 year old female patient recently developed transient urticaria and lip edema while taking Keflex and Bactrim. Symptoms improved with benadryl/dexamethasone. She has taken both meds in the past without reaction. She is off all antibiotics currently and doing fine. Should she be tested for Penicillin Allergy? If so, by serum blood test or intradermal? Does she also need testing for Sulfa allergy?
  • 72 year old female patient has sulfa listed in chart as allergy. On closer questioning of patient, she reports that symptom was limited to emesis (and may in fact have been caused by food). I want to start a diuretic for venous stasis. Most diuretics have a warning about potential cross reaction with sulfa allergy. In my opinion, she has no evidence of anaphylaxis, so I'd like to start her on HCTZ. Is this reasonable?

Endocrinology

Sample Questions

  • 30 year old male patient has elevated calcium on 2 occasions and low vitamin D with normal PTH. Patient just had a calcium oxalate kidney stone. Do you recommend pursuing parathyroid imaging vs obtaining further labs for this patient vs monitoring? He is otherwise asymptomatic aside from the kidney stone.
  • 84 year old patient who continues to have mild total hypercalcemia (max 10.8), going up slowly every time I check BMPs for an unrelated reason. The first time I saw elevated total Ca, the albumin was normal, so I checked ical and that was normal. She has a h/o vit d deficiency (treated with high dose Vit D), so I checked an intact PTH and that as normal too, Vit D deficiency improving. Only just started on ca supplements yesterday before getting labs back showing an up trending total Ca. She is on HCTZ which I can switch to something else, has CKD 2-3 likely from HTN/DM II, but her PTH is not low enough to warrant a diagnosis of non-PTH mediated hypercalcemia. Do I pursue a hyperCa workup if ionized calcium was normal?
  • Do you have any insight on why my 71 year old male patient's TSH is overly suppressed despite lowering his Synthroid dosing? What additional steps should I take?

Hematology

Sample Questions

  • 57 year old female patient with thrombophilia / VTE. Patient had remote history saddle PE after fall while on OCP, patient was as on anticoagulation with Coumadin for about 1.5 years then transitioned to ASA. Patient had gastric sleeve bypass done, now per bariatric surgery unable to take ASA? What else can be used for prophylaxis of thrombophilia / venous thromboembolism?
  • 36 year old female patient with anemia with history of bleeding fibroids and will need to increase her HgB prior to repeat myomectomy. What is the best parenteral iron formulation for IV transfusion?
  • Patient is a hemochromatosis carrier. His iron studies seem pretty stable but just wanted to confirm. What cutoffs do you use with iron studies to determine need for treatment?

Infectious Diseases

Sample Questions

  • 49 year old female patient is a candidate for Zostavax or Varicella Vaccine. Patient is asymptomatic and not at high risk for exposure. Several years ago patient had serum confirmation that she is NOT immune to Varicella--but no immunization given. She will be 50 in 2 weeks. Should she get Varicella Immunization or Zostavax?
  • 66 year old male patient had Guillain Burre 2004 (complete quad). Fortunately he recovered ability to ambulate (with walker). He had a Td and Pneumovax after 2004 (but before age 65yo). In view of hx Guillain Burre: should I avoid ALL immunizations or just flu shots?

Neurology

Sample Questions

  • 47 year old male patient received an emotionally stressful text approximately 2 months ago. He felt faint, sat down, and briefly loss consciousness for less than 5 seconds. Witnesses told him there was shaking but no incontinence or post ictal state. Several similar episodes since age 12. Patient is very athletic without syncope or dyspnea. Patient has chronic bradycardia, no hx of prior neuro or cardiac eval. Does he require additional neuro evaluation?
  • My 39 y.o. male patient had an episode of transient numbness right calf up to right thigh. Symptoms now resolved. Neg neuro exam, neg MRI brain, neg venous duplex leg. Labs normal. Was the workup appropriate and is additional testing needed?

OBGYN

Sample Questions

  • 16 year old would like to start OCPs for dysmenorrhea and mood stability. There is a strong family history of DVT and stroke, although no coagulopathies have been diagnosed. What OCP/IUD, if any would you suggest?
  • Pt's pelvic US done in 2014 showed enlarged uterus with multiple fibroids, the largest was 7cm. Pt did not have an endometrial biopsy because of the size of the fibroids. The pelvic US done this year showed: endometrium measured 3mm in size. There were 3 focal uterine fibroids the largest which measured approx. 8.5 x 8.1 x 6.5 cm. There were some calcifications associated with these fibroids. The only symptom patient has from these fibroids is increased urinary frequency. Should anything be done as the fibroids are increasing in size and patient is post-menopausal?
  • My patient’s Pap smear resulted with endocervical/Tzone component absent, is it advisable to repeat the study?
  • 48 year old woman, perimenopausal (cycle 9/2014, again 2 weeks ago), IUD mirena in place - at what time do you recommend removal of IUD? Can the fact that the IUD is in place confound her menopause status?

Orthopaedics

Sample Questions

  • 46 year old male patient with sprain of the left ankle. X ray showed cuboid fracture with no displacement and no involvement of the joint. Does he need ortho referral or casting?
  • 83 year old female patient fell last week on right side. Pt was seen in the ER and had xrays which were negative for fracture at right femur and right hip. Pt has an area of large bruise on right lateral leg and a hematoma at right upper lateral thigh. Considering pt is on warfarin, can anything be done for her painful hematoma?
  • My patient has history of bilateral hip replacements with Birmingham procedures, last 2 years ago. Does patient need antimicrobial prophylaxis before dental work?

Pulmonary

Sample Questions

  • 67 year old female patient with moderate sized 2cm right paratracheal lymph node without adenopathy in other intrathoracic, axillary, or supraclavicular regions. Could this lymph node be biopsied via bronchoscopy?
  • Male patient with HTN and HLD, who has stable indeterminate LLL 4 mm ground glass nodule, requesting guidance as to whether patient will continue to require yearly CT surveillance.
  • What is the recommended interval on CT scan to follow up for pulmonary nodule (solitary ground-glass nodules)?

Psych - Behavioral Health Associates (BHA)

Sample Questions

  • What medication(s) is recommended for the treatment of depression for a patient with uncontrolled type 2 DM?
  • Patient has a h/o recurrent severe depression. Has been on Sertraline 200 mg daily. Previously had episode of serotonin syndrome with higher dose. Has h/o substance abuse in the past. Has stopped meds due to side effects with marked erectile issues. Has h/o excision of acoustic neuroma exision and has been hesitant to use Wellbutrin. Was non-responsive with Trazadone for insomnia as well. What agents should I try?
  • Patient's oncologist has prescribed tamoxifen and is asking that her fluoxetine be stopped and another antidepressant started (due to drug interactions between these medications). I would like to switch to escitalopram (Lexapro), and would appreciate advice on how to make the switch.
  • 5 year old with depression including a recent 5 pound weight loss. EGD, colonoscopy and cancer screening all normal. PHQ score is 9. Not suicidal. His younger brother is doing well on Wellbutrin. Should I start the patient on Wellbutrin-or should I use an alternate medication because of his recent weight loss?
  • 65 year old patient has significant erosive OA at DIP of first finger (Xray completed 4/1). I recommend voltaren topical cream for her, are there further therapies that you might be able to offer her? She does not have systemic joint disease elsewhere. 

Rheumatology

Sample Questions

  • 91 year old male patient has a history of prostate cancer and wants his PSA monitored. I do not know how to interpret the change in total PSA vs. Free PSA over a 6 month time period in this patient. In January his free PSA was 0.56 and now is 0.46. However his total PSA has risen from 2.9 to 4.4 What PSA test is best for monitoring prostate cancer (free vs. Total vs. Screening)? Should he see a urologist given this rise in total PSA? What would be the next steps?
  • 69 year male old patient with BPH and history of hepatitis still having symptoms after 3 months of Flomax 0.8 and Finasteride 5mg daily. Do you recommend additional medication
  • Are physicians now recommending extended (30 days) courses of enoxaprin for ambulatory patients after a prostatectomy?

Urology

Sample Questions

  • Healthy 24 year old who had an episode of hematuria after running his first marathon a month ago and now has microscopic hematuria. Can I repeat another urinalysis in a month? Or do you recommend further testing?
  • 59 year old male patient for 2mm right renal calculus with moderate hydronephrosis and hydroureter seen at ER 3/13/15 and for office visit 3/16/16. His creatinine in the ER was 1.47 on 3/13/15, Repeated in the office on 3/17/15 and increased to 2.4 with decreased GFR. Please refer to his chart. He has been started on flomax. I will contact the patient to repeat BMP tomorrow, 3/19/15. What would be the appropriate next steps? His creatinine has increased to 2.4 and GFR decreases.
  • 56 year old female patient with kidney stones. Patient is on chronic warfarin (prophylaxis recurrent DVT). No hx of gross hematuria or dysuria or abdomen pain. No hx cystoscopy December UA had 25 rbc. Repeat UA has 9 RBC with CaOX crystals. Should I do any imaging/cystoscopy? Or just repeat UA in 3 months?

 

Upcoming Orders

eConsult Orders are being worked on for the following specialties:

  • Addictive Medicine
  • ENT
  • Hematology Pediatrics
  • Hepatology
  • Pain
  • Palliative Care
  • Sleep Medicine

 

If you have any questions or would like to see a specialty made available for eConsults, please let us know.