The Precipitants of Everything

October 2nd, 2011
by reuben in heuristic


A common mistake made by junior emergency physicians (and sometimes not junior emergency physicians) is to identify a problem and address it without considering its precipitant. Recognizing that the patient’s symptoms are due to an exacerbation of CHF, asthma, or COPD, DKA, seizure (the med student thought it was syncope but you know better), atrial fibrillation, hypoglycemia, dehydration, hepatic encephalopathy, uremia, or electrolyte disturbance: that’s fabulous. Knowing how to treat these conditions: phenomenal. But if you really want to impress the opposite sex, or the same sex, or whatever you’re into, figure out why the patient is having this problem,┬ánow. Fortunately, the same things cause most of the common afflictions of ED patients. So here they are, the precipitants of everything:


medication changes and, especially, noncompliance

recreational intoxicants and other lifestyle choices

withdrawal (but why was this patient unable to get his fix today? there may be a further precipitant)

infection (lungs, urine, skin, CNS, abdomen, indwelling catheters and devices, soft tissue/bone)

ischemia (heart, brain, bowel)


pulmonary embolism

thyrotoxicosis or hypothyroidism

occult trauma / abuse / neglect

bleeding (GI bleed, vaginal bleed, urologic bleed, retroperitoneal bleed, abdomen, thorax, thigh, street)

pregnancy (if there’s abdominal pain, bleeding, or syncope – don’t forget to rule out ectopic)


That doesn’t mean we ought to do ancillary testing to rule out these precipitants of everything; in most cases a directed history and physical is all you need. Just remember to ask the question, why is this patient having this problem, now?

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Responses to “The Precipitants of Everything”

  1. Definitely agree! As a PGY2, when I have a patient with anemia (chronic or acute) I still have the “everyone gets a rectal exam” mantra in my practice. Surprisingly, many of my resident colleagues think rectalizing every anemic patient is an overkill if there is no abdominal pain. However, I have diagnosed occult GI bleed in several cases where the admitting physician/family doc were in total agreement and it changed the in hospital course, often getting GI/surgery to scope the patient. Also helps guide the decision to transfuse/or not in NSTEMIs who are borderline Hb 9-10.

    shardy at
  2. i get no money from thinkgeek, but this seemed relevant:

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