Cough, Wheeze or Shortness of Breath: How to Evaluate? - By: Carl Davidson

Out of 100 that present with pulmonary symptoms to an emergency department or primary care setting, how many are really sick? How many have a true respiratory emergency?

Pulmonary symptoms range from bronchitis, a self-limiting problem, to a life-threatening problem, such as pulmonary embolism or congestive heart failure. If you evaluate acute pulmonary symptoms, you need a system of evaluation that is consistent, reproducible and to the highest standards of care. This was a weakness of mine when I first started my medical practice.

For four years I worked as a nighttime house officer. It was my responsibility to care for those patients that were sick enough to be admitted to the hospital, yet not quite in the ICU. I covered a respiratory wing of the hospital where I frequently responded to respiratory emergencies. I learned to sharpen my assessment skills, and decided on a better approach.

I finally made it my personal quest to master this part of my job. I ordered a lot of test, to include arterial blood gasses and chest radiographs. I didn’t have a physician close at hand, so I had to master the interpretation of a chest radiograph was also a skill I also needed to master, as a physician assistant (PA,) radiology was brushed over in my education.I had to learn the diagnostic skills to have the best patient outcomes. It was from this quest for excellence in patient care, and applying this to scores of patients, that I developed the “HOIRD” approach to pulmonary patients. For the bulk of my emergency medicine career, I have worked as a sole provider in a rural emergency department, caring for the most ill respiratory patients. I still practice using the “HORID” mnemonic; This system I have taught to thousands of providers, and it is how I practice clinically.

If you make a "HORID" mistake, your patient may die. I have developed and approach to the pulmonary approach with the mnemonic "HORID". I am saying that any patient that their primary complaint is respiratory, if you apply this mnemonic, you will follow a reasonable and logical evaluation.

H=Heart (Acute heart failure, or acute CHF) O=Obstruction (Foreign body, Croup/Epiglottisitis) R=Reactive (Such as COPD/Emphysema or Acute Asthma) I=Infection (Pneumonia) D=Death! (From a PE or pneumothorax)

I will cover all these in length, from patient presentation to diagnosis and treatment. It is critically important to learn what will kill you patient with a respiratory emergency.

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