CC: CP - MDM Documentation
Your Medical Decision Making (MDM) is the MOST important part of your chart, for billing, but also for legal purposes. When I review a case with an adverse outcome, I am looking primarily at the clinicians MDM for negligence or a failure to act according to the standard of care.
An act or failure to act by a medical professional that deviates from the accepted medical standard of care.
In all my years, I have never seen a case of willful negligence or intentional harm to a patient, and in my own practice, when I have misdiagnosed a patient, it was due to poor Medical Decision Making, usually a failure to consider the correct diagnosis.
You, my friend, are NOT going to do that because you are going to make your own template that reminds you to consider dangerous diagnoses!!!
Let’s start our MDM with the “don’t miss” diagnoses and include potential next steps to prevent missing them.
Acute coronary syndrome - after ECG and negative troponin testing, proceed to HEART score.
Acute aortic dissection - consider in patients at risk, if you're not sure, can use Aortic Dissection Detection Risk Score (ADD-RS) which is not externally validated, and not routinely used. I prefer to consider dissection based on age, risk factors, and characteristics of the presentation.
Pulmonary embolism - Well's criteria to risk stratify, apply PERC criteria, proceed to D-Dimer and/or PE CTPA if indicated
Tension pneumothorax - likely found on history and exam and probably in extremis, can do bedside U/S, CXR
Pericardial tamponade - will be in the context of hypotension, JVD, and hypoperfusion, but can consider pericarditis and evaluate for effusion bedside U/S
Mediastinitis (eg, esophageal rupture) - will likely be very ill-appearing and would get a chest CT
What about the recently stressed or imaged chest pain???
This can be confusing and nerve wracking to have a patient who just had a test for chest pain return with chest pain. They don't really fit into any pathway so here are a few tips...
A recent completely NORMAL (i.e. clean cath) cardiac catheterization within the last few years is reassuring. This is not the same as a cath with some non-critical disease.
Coronary CT angiograms are called negative if less than 50% stenosis so this is only reassuring for a few months, maybe up to 6 months.
Myocardial perfusion scans are not good at prognosis. They show tissue getting blood, not how narrow the vessels are.
I include this as tips when speaking to consultants. There is no test that would make me NOT admit a patient when I have a strong suspicion of ACS, but sometimes I have had push-back from admitting doctors.
An excellent differential diagnosis and comprehensive work-up is great, but a it needs to be documented.
Therefore, an example of MDM to include in a note could be... *** means fill in the blank
"Patient with a history of *** and *** risk factors presents with *** chest pain. ECG performed, did not show evidence of STEMI, and initial troponin was negative. Unstable angina or ACS still considered and a second troponin at 3 hours was drawn. HEART score was *** in consideration for accelerated diagnosis and discharge.
Other etiologies of chest pain considered and patient has *** risk factors and symptoms *** strongly consistent with thoracic aortic dissection. Patient has *** risk factors for PE with a Well's score of *** and PERC ***.
Patient does *** have symptoms consistent with pericarditis and bedside echo showed ***. No pneumothorax suspected. Patient is not hypotensive, septic, toxic in appearance so other dangerous intrathoracic pathology unlikely.
Skin exam negative for signs of herpes zoster or infection. No history of trauma and chest wall has *** tenderness.
I am *** suspicious for referred pain from cholecystitis, pancreatitis, or other intra-abdominal process. Reflux or esophageal pathology *** likely by history."
Whew, that's a lot. Maybe it can be shortened...
"Patient presents with non-specific chest pain with no features of pericarditis or exam findings concerning for pneumothorax and no infectious symptoms to suspect pulmonary infection. Patient does not appear septic or toxic.
Patient has *** risk factors for PE.
ACS considered with initial non-ischemia ECG and negative troponin. HEART accelerated diagnostic protocol followed and patient is *** risk.
Discussed outpatient follow-up with patient and return precautions."
Really, there is no right answer. YOU need to write what you normally do if you want to take this approach. I take my templates a step further and add in reminders for how to apply the HEART score, which is actually not fully straight-forward and gives me quick hyperlinks to calculate scores faster. You may or may not want these features, but I find that deleting these reminders is a lot faster than looking them up.
"Patient presents with non-specific chest pain with no features of pericarditis or exam findings concerning for pneumothorax and no infectious symptoms to suspect pulmonary infection. Patient does not appear septic or toxic.
Differential diagnosis includes ACS with EKG showing no ST segment elevation MI and no NSTEMI found with troponin testing negative.
ECG examined for other ischemic patterns such as ST segment depression, hyperacute or peaked T waves or abnormal T wave flattening or inversion in 2 or more contiguous leads with dominant R waves. Wellen's syndrome pattern of inverted or biphasic T waves in V2-4 was not found. If LBBB or paced rhythm on ECG, modified Sgarbossa criteria applied. A posterior MI was considered by looking for ST depression, upright T waves, tall/broad R waves, dominant R wave.
Non-specific ST segment and T wave changes include: ST depression < 0.5 mm, T wave inversion < 1 mm, T wave flattening, Up-sloping ST depression.
HEART score used in risk stratification and accelerated diagnostic protocol with second troponin at 3 hours *** and repeat EKG showing no dynamic changes.
The History of the HEART score is subjective, thus based on expert recommendation from When to Rule Out ACS, a concerning history (+2 points) is any of the following:
Chest pain PLUS vomiting, diaphoresis, radiation, or worsened with exertion.
The ECG (“E”) of the HEART was based on the pathway criteria:
Normal (including early repolarization) = 0 points
Non-specific findings (any T-wave inversions, any bundle branch block, left ventricular hypertrophy) = 1 point
ST-elevation myocardial infarction (STEMI) = 2 points
Age: <45 (0 points), 45-65 (+1 point), >65 (+2 points)
Risk factors include: HTN, hypercholesterolemia, DM; Obesity with BMI >; Current smoker or smoking cessation ≤3 mo; positive family history of parent or sibling with CVD before age 65; Known atherosclerotic disease: prior MI, PCI/CABG, CVA/TIA, or peripheral arterial disease.
Troponin testing negative.
Patient does *** have history concerning for or risk factors for aortic dissection. Aortic dissection detection risk score considered.
PE considered with *** risk factors. *** risk by Well's criteria for PE. PERC score ***.
The history and physical examination do not support a pneumothorax. Patient does *** have historical features that would indicate pericarditis.
Plan discussed with patient. Suggest outpatient follow-up with PCP and return precautions given.
