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eConsult Question Examples for Each Specialty

Allergy & Immunology

  1. How many infections over a year are when you would consider working a patient up for an immunodeficiency? What type of infections are considered worrisome for an immunodeficiency in adults?
  2. A patient develops a rash (that is not hives, but similar to poison ivy dermatitis) that is thought to be due to a contact sensitizer/antigen. Can testing be done to identify the trigger and who does this type of testing?
  3. If a patient thinks that they have food allergy, for what symptoms should I order food specific serum IgE for just those foods or a screening panel? If not, in what other options for work up and/or treatment can I offer the patient?
  4. A patient with a rash/dermatitis has seen a dermatologist outside of the UNC system who is unable to give them a diagnosis. Is it appropriate for that patient to see an allergist as suggested by that dermatologist rather than get a second opinion from an academic dermatologist?

Cardiology

  1. Questions related to anti-coagulation/anti-platelet management.
  2. Questions related to preoperative management of patients with heart disease.
  3. EKG interpretation.

Endocrinology

  1. There is a discrepancy between the TSH (normal) and free T4 (elevated). Is this clinically meaningful and does this warrant an in-patient consultation?
  2. Should an alternative osteoporosis agent be considered for my patient -on androgen deprivation therapy -who has had 5 years of alendronate , T score of -3.0 in the spine, and a BMD decline of 8% over 2 years in the hip &  spine?
  3. What is the interpretation of a TSH that is suddenly low for no obvious reason (normal T3/T4) in a patient with long-standing hypothyroidism,  on a stable dose of Synthroid 100 mcg/ day?
  4. Should my patient with a family history of autoimmunity be worked up adult onset type 1 (as opposed to type 2) diabetes , based on his clinical picture and rapid transition from oral therapy to insulin? If yes, which labs are recommended?

Gastroenterology & Hepatology

  1. 40 year old patient whose father was diagnosed with colon cancer at age 65, and paternal grandfather at age 70. When do you suggest colorectal cancer screening start and with which modality?
  2. Patient with newly diagnosed rheumatoid arthritis who is HBsAg +. Would like to start anti-TNF therapy. Please advise.
  3. Middle-aged woman with persistent heartburn despite Omeprazole 40 mg bid. No dysphagia or weight loss. Recent EGD was normal. Please recommend next steps.
  4. 19 yo college student with persistent bloating that has improved with gluten free diet for past several months. What is the best test to evaluate him for celiac disease given that she is avoiding gluten?

Geriatrics

  1. How should I assess for suspected cognitive impairment / dementia, and test for possible causes?
  2. When/how should I start AChEIs (donepezil, rivastigmine, galantamine) and/or NMDA (memantine)?
  3. My patient has a new vertebral compression fracture — I’d like some advice about pain management, and also about whether to do bone density testing and treatment for possible osteoporosis.
  4. This patient takes lots of medications — can you review the medication list and identify ways to make medications safer and simpler for a complex older patients?

Infectious Disease

  1. Interpretation of serologies and appropriate next steps (e.g. syphilis, EBV, Lyme).
  2. Antimicrobial selection for non-acute complaints or in cases of resistance, intolerance, or allergy to first-line therapy.
  3. Latent tuberculosis diagnosis and treatment.
  4. Use of vaccines and immunizations.

Hematology

  1. Patient has macrocytosis with or without anemia. Next steps in evaluation?
  2. Patient with elevated Hgb or platelet count. Next steps in evaluation?
  3. Patient with iron deficiency anemia. Poorly tolerating oral iron. When should we consider intravenous iron replacement and how do we go about it?
  4. The following types of questions are NOT appropriate for Hematology e-Consults, because these generally require careful history taking and counseling in a face-to-face clinic visit:
    1. Patient with recurrent DVT. Does patient need to be on long term anticoagulation? Or Can I stop anticoagulation in this patient?
    2. Patient with a prolonged PTT or PT/INR. Has surgery coming up shortly. Need hematology to address/clear patient for surgery.

Nephrology

  1. How should I treat electrolyte abnormalities in my patient? What are the indications and goals of treatment?
  2. How should I prescribe medications (example diuretics) or adjust medications in patients with CKD and/or electrolyte abnormalities?
  3. How should I interpret the urine analysis in my patient and what are the next steps?
  4. How should I manage resistant HTN in my patient?
  5. How can I minimize risk of Contrast induced Nephropathy? When to avoid contrast (both iodinated and gadolinium) during imaging in my CKD patients?

Oncology

  1. Patient has a history of cancer xx. Do they need any special imaging or blood work to look for recurrence?
  2. Patient has a history of cancer xx. Do they need any special preventive care (such as early mammograms in a young woman with chest radiation)
  3. Patient has abnormal imaging finding. How would you suggest I work this up?

Pulmonary

  1. What are the appropriate next steps to evaluate a patient’s dyspnea?
  2. What is the recommended management of a newly identified pulmonary nodule?
  3. What are appropriate treatment modifications for an asthmatic not responsive to LABA/ICS treatment?
  4. What is the appropriate work-up of my patient’s chronic cough?

Rheumatology

  1. What is the clinical significance of a positive, low titer ANA i.e.: 1:80? How do we work it up and does it require a formal rheumatology consultation?
  2. What are the recommendations for the acute and long-term management of gout?
  3. What are the monitoring recommendations for the monitoring of immunosuppressive medicines such as methotrexate, biologic agents, cellcept etc?

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