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Wednesday, July 20, 2011

Dr's Creed: How to diagnose and treat ER patients

So you've suffered through Medical School and are now a real ER doctor.  Don't worry, you don't have to remember all that crap you learned in school.  We've devised a cheat sheet that should help you diagnose and treat respiratory patients.  It's like taking cake from a baby. Just cut this out and paste it on the back of your keyboard for easy reference.

Emergency Room Physician Cheat Sheet
How to diagnose and treat

What's wrong with your patient.  We simply limiting it down to 10 diagnoses. 

Trouble Breathing

1.  Asthma:
  • The patient does not smoke and peak flows improve with bronchodilator.  
  • If you need to admit the patient call it exacerbation of asthma so you can get better reimbursement (if you don't, you will probably be hunted down by QA staff
  • If you need to intubate call it status asthmaticus
  • Treatment corticosteroids and breathing treatment and follow asthma order set
  • Other names you can use to have fun with quality assurance is reactive airway disease and acute bronchitis. There's no test to prove either one, so no one can argue with you. However, you may be asked to change diagnosis to asthma to assure better reimbursement.
2.  COPD:
  • The patient smokes (peak flows may increase, but most of time they don't)
  • If coughing up phlegm = bronchitis
  • If no cough and barrel chest = emphysema
  • If overweight and blue = bronchitis
  • If skinny and pink = emphysema
  • If CHF (see below) = end stage COPD
  • Treatment corticosteroids and breathing treatment (and lasix if CHF) and follow COPD order set
3.  Heart Failure:  If fluid in the lungs (BNP greater than 1,000)
  • Patient smokes = end stage COPD/ CHF and right heart failure I(write cor pulmonale every 10 patient just to mix it up)
  • If patient doesn't smoke = CHF or left heart failure (although new evidence suggests inflammatory markers may also cause left heart failure in COPD.
  • Pleural effusion = left heart failure, probably end stage.
  • Treatment diuretics and bronchodilator breathing treatment and follow CHF order set. Pleural effusions treated as appropriate or as recommended by surgeon.
4.  Pneumonia:   
  • Crackles or atelectasis in any one lobe of lung (or two lobes or three lobes).
  • Increased white blood count, pneumonia on x-ray, would easily result in a diagnosis of pneumonia.   
  • This is the default diagnosis when you have no idea what's wrong with patient because it's easily reimbursable and pays well. So, if you have a weak patient, or one from a nursing home, i.e. neurological deficit, dementia, depressed, or the family just needs a break.
  • However, the patient is weak, comes from a nursing home, or you have no idea what's wrong, then just diagnose pneumonia.
  • Treatment:  Antibiotics and bronchodilator breathing treatments (diuretics if pulmonary edema)  (Don't forget: Must have 3 failed breathing treatments in the emergency room to qualify for admission. We say this even though we know albuterol has no effect on pneumonia. If patient improves with treatment, see asthma algorithm above. If treatments fail, which they do 98.7545% of the time, then just diagnose pneumonia).

5.  Pleuro effusion
  • Line in lung on x-ray
  • Treatment chest tube and bronchodilator breathing treatments and follow pleural effusion order set (note: see CHF algorithm above if suspect heart failure is the cause).

6.  Pneumothorax
  • Trachea shift and you can see line of pleural sack in lungs on x-ray or if you put in a chest tube and you see bubbling in the air seal chamber.
  • Treatment is chest tube and bronchodilator breathing treatments and follow pneumnothorax order set
7.  Pulmonary Embolus:
  • Patient dyspnea unexplained by any other means
  • D-dimer is high and ultrasound shows PE and ABG
  • Treatment is blood thinners and bronchodilator breathing treatment and follow order set
8. Exacerbation of...: 
  •  If patient already has an underlying condition, just add "exacerbation" to that underlying condition.  Examples include:  Exacerbation of Cystic fibrosis, exacerbation of pulmonary fibrosis, exacerbation of bronchiectasis, exacerbation of lung cancer, etc.
  • Follow order set for that particular disease
9.  Mycardial Infarction:  
  • Follow ACLS protocol
  • Treatment:  MI and chest pain order set
General Disorders:

10.  Diabetes:  
  • High glucose, decreased mental status
  • Follow diabetes order set
11.  Stroke:  
  • Follow ACLS protocol
  • Treatment:  Follow ACLS protocol and stroke order set
12.  Dysthrymias:  
  • Read EKG
  • Treatment:  Follow order set for whatever EKG says
  • If symptoms admit patient and order an EKG every 2 hours and every morning for three days
  • If no symptoms order a holter monitor and send patient home
13.  Pain:
  • See location of body and where symptoms occur
  • Follow order set for general pain
  • If patient in agonizing pain, or labs are way out of whack (labs out of whack are indicated by a red color) or you're worried, call surgeon or bone doctor (osteopathic medicine)
14.  Other:  
  • If you're generally worried about patient, admit patient with diagnosis of pneumonia (see above)
  • Call family physician or Internal medicine

1 comment:

K. Scott Richey said...

At my facility it’s more like this:

Chief Complaint
Difficulty breathing = Pulmonary Consult
Chest Pain = Cardiology Consult
Abdominal Pain = GI Consult or General Surgery Consult
Fracture = orthopedic consult
Minor cuts = Surgery Consult
Head ache = MRI & neurology consult
Just plain crazy = psychiatric consult

Emergency Room is just a waiting room for consults.