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Deteriorating patient

Specialties > Child health

Differential Diagnosis Schema 🧠

Respiratory Causes

  • Pneumonia: Fever, cough, dyspnea, and hypoxia; deteriorating oxygen saturation may indicate worsening infection or sepsis
  • Pulmonary embolism: Sudden onset dyspnea, pleuritic chest pain, tachycardia, and hypoxia; deterioration may suggest extension of embolus or right heart strain
  • Acute asthma exacerbation: Wheezing, dyspnea, and decreased peak flow; deterioration may indicate worsening bronchospasm or impending respiratory failure
  • Chronic obstructive pulmonary disease (COPD) exacerbation: Worsening cough, sputum production, and dyspnea; deterioration may lead to hypercapnic respiratory failure
  • Pneumothorax: Sudden chest pain and dyspnea; tension pneumothorax can cause rapid deterioration with hypotension and tracheal deviation
  • Acute respiratory distress syndrome (ARDS): Progressive hypoxia, bilateral infiltrates on chest X-ray; deterioration indicates worsening respiratory failure
  • Aspiration: Cough, dyspnea, and hypoxia following aspiration event; deterioration may lead to pneumonia or ARDS
  • Bronchospasm: Wheezing and dyspnea, often following infection or allergic reaction; deterioration suggests severe asthma or anaphylaxis
  • Foreign body obstruction: Sudden onset dyspnea and stridor; deterioration can lead to complete airway obstruction

Cardiovascular Causes

  • Myocardial infarction: Chest pain, diaphoresis, and ECG changes; deterioration may indicate arrhythmia, heart failure, or cardiogenic shock
  • Heart failure: Dyspnea, peripheral edema, elevated JVP; deterioration may lead to pulmonary edema or cardiogenic shock
  • Arrhythmias: Palpitations, syncope, and hypotension; rapid deterioration can occur with ventricular tachycardia or fibrillation
  • Aortic dissection: Sudden severe chest or back pain, pulse deficit; rapid deterioration can lead to tamponade or rupture
  • Cardiac tamponade: Hypotension, muffled heart sounds, JVP elevation; rapid deterioration can lead to cardiac arrest
  • Hypertensive emergency: Severe hypertension with end-organ damage; deterioration may lead to stroke, heart failure, or aortic dissection
  • Septic shock: Hypotension, tachycardia, and evidence of infection; deterioration indicates worsening organ failure and requires urgent intervention
  • Massive pulmonary embolism: Sudden hypotension, hypoxia, and right heart strain; deterioration can lead to shock and death
  • Bradyarrhythmias: Slow heart rate, syncope, and hypotension; deterioration may require pacing
  • Hypovolemic shock: Tachycardia, hypotension, and cold extremities; deterioration suggests ongoing blood or fluid loss
  • Anaphylaxis: Sudden onset of hypotension, urticaria, and airway obstruction; rapid deterioration can lead to shock and airway compromise
  • Acute coronary syndrome: Chest pain, ECG changes, and troponin rise; deterioration may lead to heart failure or shock
  • Aortic stenosis: Exertional syncope, angina, and heart failure; deterioration indicates severe outflow obstruction
  • Endocarditis: Fever, new murmur, and embolic phenomena; deterioration can lead to heart failure or embolic stroke

Neurological Causes

  • Stroke: Sudden onset weakness, speech disturbance, and visual loss; deterioration may indicate expanding hemorrhage or brain edema
  • Intracranial hemorrhage: Sudden headache, vomiting, and reduced consciousness; rapid deterioration may lead to coma or death
  • Seizures: Convulsions, postictal confusion, and incontinence; status epilepticus or recurrent seizures indicate deterioration
  • Meningitis/encephalitis: Fever, headache, neck stiffness, and altered consciousness; deterioration can lead to septic shock or brain herniation
  • Hypoglycemia: Confusion, sweating, tremors, and loss of consciousness; untreated hypoglycemia can lead to seizures or death
  • Delirium: Acute confusion, agitation, and altered consciousness; worsening delirium indicates underlying cause is not controlled
  • Head injury: History of trauma, vomiting, and altered consciousness; deterioration may suggest intracranial bleeding or swelling
  • Cerebral edema: Headache, nausea, vomiting, and altered consciousness; deterioration can lead to herniation and death
  • Toxic/metabolic encephalopathy: Confusion, altered consciousness due to renal or hepatic failure, toxins, or drugs; deterioration may require ICU admission
  • Guillain-Barré syndrome: Progressive limb weakness, areflexia, and respiratory failure; deterioration can lead to paralysis and need for mechanical ventilation
  • Myasthenic crisis: Generalized muscle weakness, ptosis, and respiratory failure; deterioration requires ICU admission and ventilatory support
  • Non-convulsive status epilepticus: Prolonged altered consciousness without obvious convulsions; deterioration can lead to brain damage if untreated
  • Cerebral abscess: Fever, headache, focal neurological signs; deterioration suggests rupture or increased intracranial pressure
  • Subarachnoid hemorrhage: Thunderclap headache, neck stiffness, photophobia; deterioration indicates rebleed or vasospasm
  • Brain tumor: Headache, seizures, focal neurological signs; deterioration may suggest increased intracranial pressure or hemorrhage
  • Hydrocephalus: Headache, nausea, vomiting, papilledema; deterioration suggests increased intracranial pressure

Metabolic and Infectious Causes

  • Sepsis: Fever, tachycardia, hypotension, and altered mental state; rapid deterioration can lead to septic shock and multi-organ failure
  • Diabetic ketoacidosis (DKA): Polyuria, polydipsia, vomiting, and altered consciousness; deterioration can lead to coma and death
  • Hyperosmolar hyperglycemic state (HHS): Severe dehydration, hyperglycemia, and altered mental state; deterioration can lead to coma and death
  • Hypoglycemia: Confusion, sweating, tremors, seizures; untreated hypoglycemia can lead to coma and death
  • Acute kidney injury: Oliguria, elevated creatinine, and electrolyte imbalance; deterioration can lead to metabolic acidosis and multi-organ failure
  • Hepatic encephalopathy: Confusion, asterixis, and jaundice; deterioration can lead to coma and death
  • Severe electrolyte imbalances (e.g., hyperkalemia, hyponatremia): Muscle weakness, arrhythmias, and altered mental state; deterioration can lead to cardiac arrest
  • Thyroid storm: Fever, tachycardia, and altered mental state; deterioration can lead to heart failure and death
  • Adrenal crisis: Hypotension, hypoglycemia, and altered mental state; deterioration can lead to shock and death
  • Uremic encephalopathy: Confusion, asterixis, and lethargy in chronic kidney disease; deterioration can lead to seizures and coma
  • Alcohol withdrawal: Tremors, seizures, and delirium; deterioration can lead to delirium tremens and death
  • Drug overdose: Altered mental state, respiratory depression, and hypotension; deterioration can lead to coma and death
  • Toxic megacolon: Abdominal pain, distension, and fever in severe colitis; deterioration can lead to perforation and sepsis
  • Heat stroke: Hyperthermia, confusion, and hypotension; deterioration can lead to multi-organ failure and death
  • Hypothermia: Shivering, confusion, and bradycardia; deterioration can lead to cardiac arrest
  • Rhabdomyolysis: Muscle pain, dark urine, and elevated creatine kinase; deterioration can lead to acute kidney injury and death
  • Severe infection (e.g., meningitis, encephalitis): Fever, headache, neck stiffness, altered mental state; deterioration can lead to septic shock or brain herniation
  • Necrotizing fasciitis: Rapidly spreading soft tissue infection; deterioration can lead to septic shock and death
  • Severe pancreatitis: Abdominal pain, vomiting, and systemic inflammation; deterioration can lead to multi-organ failure
  • Tetanus: Muscle rigidity, spasms, and autonomic instability; deterioration can lead to respiratory failure
  • Severe anemia: Fatigue, pallor, and tachycardia; deterioration can lead to heart failure or shock
  • Toxic shock syndrome: Fever, rash, hypotension, and multi-organ failure; deterioration can lead to shock and death
  • Anaphylaxis: Rapid onset of hypotension, airway obstruction, and rash; deterioration can lead to shock and death
  • Severe dehydration: Confusion, tachycardia, and hypotension; deterioration can lead to shock and multi-organ failure
  • Hypercalcemia: Confusion, polyuria, and abdominal pain; deterioration can lead to arrhythmias and coma
  • Hyperparathyroidism: Hypercalcemia with bone pain, fractures, and abdominal pain; deterioration can lead to severe hypercalcemia and multi-organ dysfunction
  • Hyperthyroidism: Weight loss, palpitations, and heat intolerance; deterioration can lead to thyroid storm
  • Hypothyroidism: Weight gain, cold intolerance, and lethargy; deterioration can lead to myxedema coma
  • Hypoglycemia: Sweating, tremors, and altered mental state; deterioration can lead to seizures and coma
  • Hyponatremia: Confusion, nausea, and seizures; deterioration can lead to cerebral edema and death
  • Hypokalemia: Muscle weakness, arrhythmias, and constipation; deterioration can lead to paralysis and cardiac arrest
  • Hypomagnesemia: Muscle cramps, arrhythmias, and seizures; deterioration can lead to cardiac arrest
  • Hypophosphatemia: Muscle weakness, confusion, and respiratory failure; deterioration can lead to multi-organ failure
  • Acidosis (metabolic/respiratory): Confusion, lethargy, and hyperventilation; deterioration can lead to coma and death

Key Points in History 🥼

Onset and Duration

  • Acute vs. gradual deterioration: Sudden deterioration suggests acute events like PE, MI, or stroke, while gradual worsening suggests infections, heart failure, or metabolic causes
  • Preceding symptoms: Chest pain, dyspnea, fever, or weakness may provide clues to the underlying cause
  • Triggering factors: Identify recent changes like surgery, new medications, or infections that could have precipitated deterioration
  • Prior similar episodes: History of previous similar events can suggest recurrent conditions like seizures, arrhythmias, or asthma
  • Associated symptoms: Pain, dyspnea, fever, neurological changes, and other symptoms should be documented
  • Response to treatment: Note any treatments that have been given and their effectiveness, as well as any adverse reactions
  • History of chronic illness: Conditions such as COPD, heart failure, diabetes, or renal disease that might contribute to deterioration
  • Medications: Recent changes, adherence, or potential drug interactions that could have contributed to deterioration
  • Social history: Consider factors like alcohol or drug use, social support, and living conditions that might affect the patient’s ability to cope with illness
  • Travel history: Recent travel might suggest infectious causes, especially in regions with endemic diseases like malaria or dengue
  • Allergies: Note any known allergies, particularly if anaphylaxis is suspected
  • Family history: Consider hereditary conditions or a family history of sudden death, arrhythmias, or thromboembolism
  • Surgical history: Recent surgeries can be a source of complications such as infections, DVT, or PE
  • Psychosocial factors: Mental health issues, stress, and coping mechanisms can influence the response to illness and treatment adherence

Possible Investigations 🌡️

Initial Bedside Tests

  • Vital signs monitoring: Continuous monitoring of heart rate, blood pressure, respiratory rate, and oxygen saturation to detect early signs of deterioration
  • Capillary blood glucose: To assess for hypoglycemia, particularly in diabetic patients or those with altered consciousness
  • 12-lead ECG: To assess for arrhythmias, myocardial infarction, or signs of electrolyte disturbances
  • Arterial blood gas (ABG): To assess for hypoxia, hypercapnia, acidosis, or metabolic derangements
  • Pulse oximetry: To assess for hypoxia, particularly in respiratory or cardiac deterioration
  • Urinalysis: To assess for infection, dehydration, or signs of metabolic or renal dysfunction
  • Neurological examination: To assess for focal neurological deficits, suggestive of stroke, infection, or other CNS pathology
  • Temperature: To assess for fever, hypothermia, or sepsis
  • Fluid balance chart: To monitor input and output, particularly in patients with renal or cardiac deterioration
  • Consciousness level (GCS): To monitor for deterioration in neurological status, particularly in head injury or CNS infection
  • Blood cultures: To identify bacteremia or sepsis, particularly in febrile or hypotensive patients
  • Electrolyte assessment: To detect imbalances such as hyperkalemia, hyponatremia, or acidosis
  • Peak flow measurement: In asthma or COPD exacerbations, to assess respiratory function and response to treatment
  • Venous blood gas (VBG): To assess lactate, bicarbonate, and base excess in deteriorating patients
  • Cardiac monitor: Continuous monitoring for arrhythmias in patients with cardiac deterioration
  • Urine output monitoring: To assess for acute kidney injury or hypovolemia
  • Chest auscultation: To detect crackles, wheezes, or reduced breath sounds indicative of respiratory pathology
  • Bladder scan: To assess for urinary retention or post-renal causes of deterioration
  • Skin assessment: To identify signs of sepsis, dehydration, or skin breakdown in deteriorating patients
  • Oral mucosa assessment: Dry mucous membranes may indicate dehydration or sepsis
  • Pulse palpation: To assess for arrhythmias or peripheral perfusion issues in deteriorating patients
  • Blood glucose monitoring: Frequent monitoring in diabetic patients or those with altered mental status
  • Pupil assessment: To detect signs of raised intracranial pressure or neurological deterioration
  • Sepsis screening tool: To rapidly identify patients at risk of sepsis and initiate early treatment
  • Capillary refill time: Prolonged refill time suggests hypovolemia or poor perfusion
  • Oxygen therapy: Immediate administration for hypoxic patients, adjusting flow as needed

Laboratory and Imaging Investigations

  • Full blood count (FBC): To assess for infection, anemia, or thrombocytopenia.
  • Urea and electrolytes (U&E): To assess renal function and electrolyte imbalances.
  • Liver function tests (LFTs): To assess for liver dysfunction or failure.
  • Coagulation profile: To assess for coagulopathy, particularly in patients with liver disease or suspected bleeding.
  • Thyroid function tests: To assess for hyperthyroidism or hypothyroidism as a cause of deterioration.
  • Chest X-ray: To assess for pneumonia, pneumothorax, pulmonary edema, or other thoracic causes of deterioration.
  • Echocardiogram: To assess cardiac function in patients with suspected heart failure or valvular disease.
  • CT brain scan: To assess for stroke, hemorrhage, or space-occupying lesions in patients with neurological deterioration.
  • Abdominal ultrasound: To assess for abdominal causes of deterioration such as cholecystitis, pancreatitis, or bowel obstruction.
  • CT pulmonary angiogram (CTPA): To assess for pulmonary embolism in patients with respiratory deterioration.
  • Serum lactate: Elevated in sepsis, shock, or severe hypoperfusion.
  • Blood cultures: To identify causative organisms in sepsis or bacteremia.
  • Cardiac enzymes (troponin): To assess for myocardial infarction in patients with chest pain or ECG changes.
  • Toxicology screen: To identify drugs or toxins in cases of suspected overdose or poisoning.
  • Serum ammonia: To assess for hepatic encephalopathy in patients with altered mental status.
  • Urine culture: If urinary tract infection is suspected as a cause of sepsis or deterioration.
  • Serum bicarbonate: Low in cases of metabolic acidosis associated with severe dehydration or renal failure.
  • Serum calcium: Elevated in hypercalcemia or parathyroid disorders.
  • CSF analysis: In cases of suspected meningitis or encephalitis with neurological deterioration.
  • Serum paracetamol/salicylate levels: To assess for overdose in patients with altered mental status.
  • Serum ketones: Elevated in DKA, particularly in diabetic patients with dehydration or altered mental status.
  • Venous blood gas (VBG): To assess lactate and bicarbonate.

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