Going into the dark rooms with radiation

Requesting an ultrasound/CT for your patient.

Today is the third time for me to go to the Radiology department to request a test for my patient. Nobody really told us how to present a case good enough to convince the Radio MO that the test is really needful for your patient. Based on my experience, the presentation must not be very formal-like. But it should consist of precise information that radiologists will want to know.

I was referring a case of a brain metastasis with primary lung lesion to the department because there was sudden desaturation of the patient. I want to exclude pulmonary embolism because Well Score for the patient was pretty high. Therefore, I requested for a CTPA.

Wells' criteria risk stratifies patients for PE. It is not a diagnostic scoring system per se, but it is a guide to predicting pre-test probability of PE.

Clinical ssx of DVT (3)

PE is first diagnosis or equally likely (3)

Heart rate > 100 (1.5)

Immobilization at least 3 days or surgery in the past 4 weeks (1.5)

Previously objectively dx PE or DVT (1.5)

Hemoptysis (1)

Malignancy without treatment within 6 months or palliative (1)

</=4  as PE unlikely

 >4  as PE likely

This is how I presented my case.

Good morning Dr XXX

I'm from ward XX and I'd like to request for a CTPA urgent for my patient.

My patient is a known case of brain mets with primary lung lesion dx 2 months ago, currently not on chemotherapy yet. We notice a sudden desaturation of the patient in the ward. Under room air SpO2 dropped from 97 to 95 and then to 92. We put patient under NpO2 but SpO2 further dropped to 90%. Currently patient is placed on Venturi mask 35%. SpO2 is maintained 90-95%. 

At this time, the doctor would have agreed to grant the request. However, it is the time to continue letting the MO know that you have taken consent for the patient (since it's a contrast enhanced test), and that you've had the most recent Renal Profile results stated on the consent form. The doctor would want to know the creatinine level of the patient. If it is >100, the patient will need to be given T. NAC 600mg BD. Since my patient is also an asthmatic, she is given IV hydrocort 100mg stat once the request was granted. Inform the MO that a green branula has been set on the patient because it is the suitable branula size needed for the contrast. One important thing is that the patient should be fasted for at least 8 hours. Of course if it's an urgent case like this one, the request was granted as soon as possible. 

Yup. Good luck.

On a side note, I didn't really like to go down to the radio department because I never could present a case nicely without being questioned on things I couldn't answer. The MO will finally need to call up my medical MO to ask for further details. It's a shame to me. But it's my first time to request for a CT for my patient all on my own. I still think I did a good job. 

There will be more to come. Stay tuned. Stay strong and positive :)