- Can your next patient give a complete, honest,
and accurate history?
- Will you be able to access her
medical records?
- Did you get a good hand-off? Does
anyone on your shift know her?
- Have any of those
factors changed during the course of her visit?
Whether you serve a low-volume community
hospital or a jam-packed urban teaching center, your
population presents a broad diversity of complaints.
You hope the patients, from Little Leaguers to
octogenarians, can provide context of this visit and
their medical history. Often, however, you will
need more information from family, records, or
colleagues in order to narrow—or broaden—your
diagnostic focus.
If insufficiently integrated EMRs leave you prone
to missing key clinical information, you must pay extra attention to the symptoms your patient
or her family members express the most concern
about. This, of course, has to be balanced against co-morbidities and any tendency to focus on a
diagnosis you may have initially presumed.
Patients presenting with multiple traumas may draw
multiple caregivers, but the poor historian with
vague belly pain might demand equal vigilance.
A patient with a significant medical history and
affirming symptoms also poses the risk of a
plausible answer that may limit your differential
diagnosis, even when contrary clues are present.
Increasing volume amplifies the pressure as you and
your ED colleagues contend with the slow simmer of
patients’ discomfort, persistent distractions, and the
queue in the waiting room. Amidst this everyday
chaos lies the risk of critical patient information
getting lost en route to those of you working to
make management decisions and safe dispositions.
Therein, potentially, is the difference between an
expertly managed course in the ED or a slightly off-target
trajectory ending in harm for patients whose
condition changed over time.
Case Example: Assessment
A 49-year-old with a history of hypertension and cardiomyopathy presented to the ED with complaints of eye pain, blurred vision,
and unsteady gait since the previous evening. After a limited physical exam, he was sent to the eye clinic for evaluation. Absent
radiological studies or neurological consults, the patient was discharged with a diagnosis of corneal abrasion, macular elevation,
and hypertension retinopathy. The following day, he returned to the ED with continued blurred vision and headache, and was noted to
have altered mental status. CT scan revealed posterior and anterior artery stroke, leaving the patient with permanent visual impairment
and cognitive deficits. (Case settled: $2.2M)