Lecture Notes
It’s really easy to pick up on the sick patient that looks sick. It’s much harder to identify the sick patient if he or she looks well and is in a sea of well-looking patients. In this lecture, we aim to give you an approach to better identify these needles in the haystack.
Approach to Identifying the Acute or Critical Patient During a Medical Screening Exam
Basically we want to rapidly separate patients that may have true Emergent pathology vs those that can stay in the waiting room or be evaluated in a non-ER setting.
In particular, we want to separate out the subtlety sick compared to the walking well.
A medical screening exam (MSE) usually takes less than a minute and can be accomplished with a very quick history, focused physical, and ultra-quick chart review (Triage note/VS/medical hx)
Step 1: Evaluate how the patient looks “sick versus not sick”
Diaphoretic, pale, dyspneic, obtunded, something just doesn’t look right?
If so, the patient should be evaluated in the ED.
If not, move on to step 2
Step 2: Vital signs
It’s easy if the patient is hypotensive or significantly tachycardic, bradycardia, or hypoxic.
Keep in mind, tachycardia and mild tachypnea may occur because of a fever. Consider checking a core temperature or a lower threshold for ER evaluation.
Next, review the respiratory rate (RR). The RR is a subtle sign of acute, critical illness. Even mild elevations should be concerning. The triage vital signs may not be correct, evaluate for tachypnea yourself.
If concerning vital signs => ED. If not, move on to step 3
Step 3: Wild cards
Wild cards. Does the patient have any specific risk factors for hidden illness?
Elderly i.e >75
Immunosuppressed - e.g. AIDS, immunosuppressive medications, chemo
Complex surgical history such as transplant patients
If the patient has any of the above they may be hiding a more ominous process and may warrant ED evaluation. For example, a fever in an elderly or immunocompromised individual typically requires at least an ED workup and possible admission.
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