"Vigilance" Never Goes Out of Style

As any experienced urgent care practitioner knows, the true clinical challenge in urgent care is to remain sharp and vigilant- ever aware- for the rare but real urgencies and emergencies that could otherwise get lost in the daily drone of clinical minutia. Consider the "sinus headache" that 3 hours later is a subarachnoid hemorrhage. At least in the emergency room the basic volume, due to selection bias, of clinical catastrophes is enough to prod one to awareness. Urgent care lacks that daily external prodding, which means as a professional, the drive to vigilance must derive from an internal source.

THAT SOURCE IS YOU.

As a reminder of this, consider the mnemonic of "vigilance." Yes, it is cheesy, but it may come in handy at 7:59:59pm with that last patient walking through the door. Note that vigilance is not excessive or overbearing workups as much as it is constantly remaining open to the worst-not the best-outcome, and then guarding properly against it.

•  v is for vision/snellen charts. It is hard to say you "did no harm" unless you document the damage present before your exam. Also, it may be a tip off to acute angle glaucoma or occult globe perforation (as occurred in Wakefield).
• I is for incision and drainage. With CA-MRSA, only good usually comes from this procedure. Much like intubation, "if you think an abscess may need I&D", then it should be done. You and the patient will sleep better.
• G is for a general view of the patient. As a past pediatric article mentioned, your global, "gut" impression can go a long ways to ruling out occult sepsis.
• I is for proper inquiring.  Medical students only wonder about answering the questions a patient has. Experienced clincians wonder why the patient is asking the question in the first place.
• L is for looking at skin (in areas of pain) to confirm no visible Zoster. We all have heard of the "heart attack" that showed itself to be shingles when a patient's shirt came off, but what about the vesicles hiding in the scalp for a patient's "headache."
• A is for acknowledging that you cannot remove all the uncertainty from clinical decision making (even though society and lawyers expect us to), but you can "do enough to get comfortable with your uncertainty."
• N is for pertinent negatives. Newbie diagnosticians often focus on exam findings that are present, but be sure to document important findings that are not present.
• C is for credit. Remember you can never give enough credit to your nurses, lab techs, and x-ray techs. They supply the data points that you assemble into a cohesive picture.
• E is for efficiency. Ideally, for nearly every chief complaint, walk into the room with the top 1 to 3 things that you want to rule out, and then proceed. For many general, nonspecific issues, sometimes telling the patient what he/she does not have can be as reassuring as finding (the perhaps non existent) answer.

Are there any pearls you all would add?