Guest Post: Physicians: Use your continued clinical judgement when determining diagnoses

by Robert S. Gold, MD

Physicians in the ED setting must make observations and determinations rapidly. Differential diagnoses often precede hospital admission. Sometimes all you have are symptoms, but you know the patient is very sick. Sometimes you know exactly what that sickness is. Sometimes a lab result will lead you down a path of diagnostic tests and treatment modalities that, after study, weren’t so necessary or were just wrong.

Keep some of these issues in mind, whether in the ED or on the medical-surgical units, when you document your ongoing evaluation of patients.

In the remainder of this article we will discuss some familiar concerns and possible alternatives.

Potassium levels in the range of seven or so (you know to look for the possibility of hemolysis before administering glucose, insulin, and Kayexelate). Blood pressure of 60/40 in a patient who just looks too healthy (you know to repeat the blood pressure on the opposite arm before starting boluses and pressors). These don’t represent hyperkalemia and shock. They’re abnormalities.

Is a creatinine of 3.4 acute kidney injury (AKI)? A patient may come into the hospital with signs of severe illness. On the initial workup that would likely include a complete blood count with differential and complete metabolic panel, you might find a significantly elevated creatinine. If the patient’s condition looks like it could be associated with renal damage, you might initially call this AKI or acute renal failure. And depending on the perceived mechanism, whether consistent with a prerenal, intrarenal, or postobstructive condition, you’ll institute appropriate therapy.

However, when you know—from previous encounters with this patient or after the institution of treatment—that the creatinine level is high but hasn’t moved, the problem could be an elevated creatinine related to chronic kidney disease (CKD). You should confirm in the progress notes that what was originally thought to be AKI on admission turned out to be CKD stage 3 due to the patient’s diabetic nephropathy, or whatever mechanism you concluded caused the problem.

Is a B-type natriuretic peptide (BNP) of 5,600 indicative of a patient with acute congestive heart failure(CHF)? A patient may be admitted with shortness of breath, either new or worse than before. The chest film may be interpreted as having cardiomegaly and maybe even pulmonary vascular congestion. And your response to this, in view of a BNP of 5,600, might be to administer a diuretic. Well, many of these cases turn out to be nothing other than acute CHF; however patients with end-stage CHF with significant systolic dysfunction and ejection fractions in the range of 15%–25% may very well walk around normally with a BNP of 5,600—or even considerably higher! And the shortness of breath may really represent a cold, sinusitis, or pneumonia.

Be wary of the end- stage renal disease (ESRD) patient or the patient with cor pulmonale who is volume overloaded in the best of times. Once it is recognized that the patient has another reason for the elevated BNP level, be sure to document the following: What was the diagnosis initially thought to be? Acute diastolic heart failure on admission may turn out to be a reflection of the patient’s end-stage heart (or renal) disease.

Does an albumin of 1.6 always reflect ‘severe malnutrition’? Not on your life, although some people at your hospital may want you to document “severe malnutrition” based on a single determination of serum albumin. Say the patient has a long-standing protein losing enteropathy or nephropathy or is in severe eclampsia. Further, the patient has an albumin level of 1.6 while playing intramural or interoffice sports. No way does the patient have “severe malnutrition.”

Is a hemoglobin of 9.8 after surgery ‘acute blood loss anemia’? Don’t fall into the trap. If the patient started with a hemoglobin of 9.7 because of end-stage renal disease, sickle-cell disease, chronic hepatitis, or chronic blood loss from the cecal cancer on which doctors operated, forget it! The anemia existed prior to admission. Perhaps a patient goes into surgery with a hemoglobin of 12. Because of the patient’s diabetic peripheral neuropathy, he requires 2.5 liters of crystalloid to maintain blood pressure perioperatively. The estimated blood loss in the case is 50 cc. Is there a chance the hemoglobin drop was purely dilutional? Don’t respond automatically with “acute blood loss anemia” when evidence shows that there was another specific cause. And don’t respond you know it wasn’t anemia due to acute blood loss.

Is an elevated troponin an acute myocardial infarction (MI)? A patient may appear in the ER or in your office with crushing chest pain or weakness and diaphoresis and maybe an irregular heart rhythm. An EKG shows no acute ST wave changes or deep Q waves, but the troponin level comes back as 0.4 with the lab’s high normal at 0.03. Is that a non-ST elevation MI? Could be! While you’re thinking about administering aspirin and working the patient up for the possibility of sending him or her on to the cath lab, take a look at several options. Is it an MI? Is it a non-ST elevation MI caused by a demand issue as might happen with shock or severe anemia or hypertensive emergency? Is it an MI caused by arteritis or coronary artery spasm or Kawasaki disease? Or does the patient have a massively enlarged heart, whether dilated or hypertrophied, with ongoing compromise of the myocardium; in this case you’ll likely find that the subsequent troponin levels were the same as the admission level and an acute MI did not occur. Does the patient have ESRD and a consistently elevated troponin level? In these instances, be sure to clarify in your notes that a MI probably did not occur.

In all of these instances, “copy and paste” day after day with the same diagnoses that never change and show no complexity of medical decision-making. However, be sure to clarify when you know that something that was considered on admission was ruled out!

Editor’s Note: Dr. Gold founded DCBA, Inc., in Atlanta, a consulting firm that provides physician-to-physician programs in clinical documentation improvement (CDI) and training of CDI specialists to support the needs of the medical staff. This article originally published in the July 2012 edition of Medical Records Briefings. Advice given is general. Readers should consult professional counsel for specific legal, ethical, or clinical questions.