Wednesday, January 4, 2012

Critical thinking corner: What are the missing orders?

Hey diagnosticians and treateurs of illnesses!  Care of our friend Dr. Big Work-Up, try to figure out what orders are missing from this hugeass, soul-sucking workup for the following patient:

Patient is a middle-aged male with a long history of asthma and no other chronic medical conditions.  He has been using his inhaler frequently for the last week.  He called 9-1-1 for an acute asthma exacerbation, not relieved with his usual inhalers.  Paramedics found him with labored respirations, inability to speak in full sentences, and very distant if not absent breath sounds bilaterally with the following vital signs:

  • BP 138/65 
  • HR 88 and regular
  • Sats 86% on room air
  • RR of 36
  • Temp [done in ER] of 98.1
The medics gave a neb, started a line, and drove the patient in the short distance to the hospital.  His breathing persisted in a similar fashion, but his oxygen came up to 93% on 3L of O2.  The chest x-ray done right away was read as clear.  He's only on an albuterol inhaler and has no allergies.  

Here is the set of orders on my screen:
  • Chest x-ray 
  • EKG 
  • Saline lock
  • Cardiac/vital sign monitoring
  • CBC, Lytes, Troponin, cortisol (huh?), lactate (afebrile,  no signs of sepsis), INR (not on Coumadin)
  • Blood cultures x 2 (X-Ray was negative for pneumonia prior to physician eval + afebrile)
  • UA (Because shortness of breath in an asthmatic middle-aged adult is likely caused by a urinary tract infection)
Okay kids, now here's where you come in with the Where's Waldo stuff.  What is this order set missing?  

27 comments:

  1. Actually, a blood gas was done. My bad there. D-Dimer could have been done, but he's a healthy dude with a normal heart rate, etc.

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  2. Alb neb? Maybe a BNP just for kicks. Unless your ED needs an order for "oxygen therapy"?

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  3. Peak flow? Won't reveal beyond the obvious... but cheap, minus 1 minute of time.

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  4. D-dimer, CT chest, ECHO....and if it's OUR Dr. Big Work-up...consult Internist for admission (before labs or any other diagnostic is done)

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  5. Head CT, spinal tap, EEG. And a neurology consult to determine if the breathing issue is from undiagnosed Myasthenia Gravis.

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  6. ^^ Now we're talking about the next episode of House.

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  7. Hrm... I know! They forgot to break out the Rape Kit! ... No? I guess it's a good thing I'm not a physician, then.

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  8. He needs one of the 'sones. And a long acting inhaler of sorts, cause wtf?

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  9. CT chest or if he's really psycho, VQ scan

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  10. And in the spirit of big work ups, where's the pulmonology or intensivist consults?

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  11. Uh, how about something to actually help his breathing? Please, please tell me he did order something like mag or solumedrol?

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  12. Well, lets treat his ASTHMA. So how about some prednisone and ipatropium.

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  13. I guess the answer is steroids but it'd be more fun to get a cardiac MRI to look for restrictive cardiomyopathy caused by sarcoidosis.

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  14. BiPAP, hour long A&A neb and start the steroids.

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  15. Yes, in my opinion, those of you who decided to, like, ya know, TREAT THE ASTHMA with nebs/steroids or stuff like hour of BiPAP are correct!!

    Of course, it never hurts to get a negative d-dimer and then do a chest CT to check for PE anyway or related to keep your Big Work-Up street cred up.

    Obviously, I'm like, yo, how's about some solumedrol and some nebs up in this bitch?

    "Oh, that sounds like a good idea."

    Remember kids, don't get bogged down by Big Work-Ups (TM) because Big Work-Upeurs are also often undertreaters. DKA with no fluids ordered, anginal chest pain with no nitros, fevers with no Tylenol, you name it.

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  16. Shoot - i am not even a doc or nurse and i knew to do the nebs for asthma....just a mom with a kid with asthma

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  17. don't know how it posted to my daughter's name...crazy cady is actually lestatbp

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  18. What no pregnancy test in case this he is a she?

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  19. I can't believe there's not a CRP or BNP.

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  20. Aww...I thought for sure you'd say get him a drug screen just to see what he's taking (since he nicely peed in the cup).

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  21. ER did an ABG on my 90 year old patient with a history of CHF, a bnp of 4200, and who was satting at 98% on RA because she was SOB. Do these people try and find ways to torture people?

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  22. What, no order for incentive spirometry? The guy is short of breath, so clearly you need to measure *exactly* how short of breath he is, before you can consider doing anything useful.

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  23. >>Big Work-Upeurs are also often undertreaters.<< I read that as "Big Work-Upeurs are also often UNDERTAKERS".

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  24. This comment has been removed by the author.

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