http://tjuh.jeffersonhospital.org/intranet/index.cfm?fuseaction=cNews.main

Chart completed late because ED was too busy at time of pt visit

Discharge

Prior to discharge I discussed the d/c diagnosis with the patient, reasons to RTER, and plans for f/u.  All patient questions were addressed.  The patient understood this discussion and wanted to be discharged.

The pt was awake and alert, GCS 15, looked well, reported that their sx's were much improved, and was ambulating without difficulty.

Wells Score for PE


Clinical Signs and Symptoms of DVT (3) - NO
PE Is #1 Diagnosis, or Equally Likely (3) - NO
Heart Rate > 100 (1.5) - NO
Immobilization at least 3 days, or Surgery in the Previous 4 weeks (1.5) - NO
Previous, objectively diagnosed PE or DVT (1.5) - NO
Hemoptysis (1) - NO
Malignancy w/ Treatment within 6 mo, or palliative (1) - NO

(Probability = Low)

PERC Rule

Age < 50
HR < 100
O2 Sat on Room Air > 94%
No Prior History of DVT/PE
No Recent Trauma or Surgery
No Hemoptysis
No Exogenous Estrogen
No Clinical Signs Suggesting DVT

Based on my history and physical examination I have a very low suspicion that this patient's symptoms are due to a PE.  Combined with a negative PERC Rule I think patient has a very low clinical probability for PE.


TIMI Risk Score for UA/NSTEMI

Age < 65 years
Less than 3 Risk Factors for CAD (FHx of CAD, HTN, HL, DM, Current tobacco)
No known CAD (stenosis ≥ 50%)   
No ASA Use in Past 7 days
No severe angina (> or = 2 episodes w/in 24 hrs)
No ST changes > or = 0.5mm
Negative initial Cardiac Marker

Original paper
Summary


HEART Score

History
ECG
Age
Risk Factors (HL, HTN, DM, Obesity, Tobacco, FHx) Troponin
Points
Slightly suspicious Normal
< 45 years
None
Negative
0
Moderately suspicious Non specific repolarisation disturbance 45 - 65 years
1 -2
1 - 3 x normal limit
1
Highly suspicious Significant ST-depression > 65 years
3 or more -or- PMH of Athersclerosis
> 3 x normal limit
2
 
Score
Risk of Major Adverse Cardiac Event within 6 weeks
0 - 3
0.9%
4 - 6
12%
7 - 10
65%

Derivation
Validation


ABCD2 Score for risk of stroke after TIA

Factor
Points
Age > or = 60
1
Initial BP > 140/90
1
DM
1

Symptoms
Duration
Points
Other
< 10 min 0
Speech impairment without weakness 10‐59 min 1
Unilateral weakness > 60 min 2


0-3 Points
(Low Risk)
4-5 Points
(Moderate Risk)
6-7 Points
(High Risk)
2-Day Stroke Risk 1%
4.1%
8.1%
7-Day Stroke Risk 1.2%
5.9%
11.7%
90-Day Stroke Risk 3.1%
9.8%
17.8%


Ottowa Ankle/Foot Rule

No bony tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus
No bony tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus
No bony tenderness at the base of the fifth metatarsal
No bony tenderness at the navicular bone
Patient was able to bear weight both immediately after injury and also in the emergency department for four steps


Ottowa Knee Rule

Not age 55 years or older
No tenderness at head of fibula
No isolated tenderness of patella
Able to flex to 90
Able to bear weight both immediately and in the emergency department (4 steps)


NEXUS (age 1 and up)

No tenderness at the posterior midline of the C-spine
No focal neurologic deficit
Normal level of alertness (GCS 15, AAO x 3)
No evidence of intoxication
No clinically apparent pain that might distract the patient from the pain of a C-spine injury


Canadian C-Spine Rule

Not 65 or older
No dangerous mechanism
Sitting position in emergency department
Ambulatory
Absence of midline cervical spine tenderness
Can actively ROM 45 degrees both left and right

Dangerous mechanism of injury: fall from an elevation ≥3 ft or 5 stairs, axial load to head, high speed (>100 km/hr) MVA, MVA with rollover or ejection

The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma


Canadian Head CT Rule (age 16 and up)

Not 65 or older
GCS 15
No identified open or depressed skull fracture
No sign of basilar skull fracture
Not more than 1 episodes of vomiting after the injury
No amnesia for events 30 minutes prior to injury
Not dangerous mechanism of injury

Dangerous mechanism of injury: pedestrian struck by vehicle, occupant ejected from motor vehicle, fall from elevation ≥3 feet or 5 stairs

Prediction Value of the Canadian CT Head Rule and the New Orleans Criteria for Positive Head CT Scan and Acute Neurosurgical Procedures in Minor Head Trauma


PECARN CT-Head Rule (Comparison of PECARN)

< 2 years of age

GCS 15 – YES
No palpable skull fracture – YES
No altered mental status – YES
No scalp hematoma (frontal is acceptable) – YES
LOC < 5 seconds – YES
Non-severe mechanism of injury – YES
Normal behavior per parent – YES


2 years of age and up

GCS 15 – YES
No altered mental status (agitation, somnolence, repetitive questioning, slow response to verbal communication) – YES
No signs basilar skull fracture – YES
No LOC – YES
No vomiting – YES
Non-severe mechanism of injury – YES
No severe headache – YES


Severe mechanism of injury: motor vehicle crash with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without helmet struck by a motorized vehicle; falls of more than 3 feet (< 2 years) or more than 5 feet (2 and up) or head struck by a high-impact object.

Patients with certain isolated findings such as isolated LOC, isolated headache, isolated vomiting, and certain types of isolated scalp hematomas in infants older than 3 months have a risk of ciTBI substantially lower than 1%.

Pediatric head trauma - TBI and VOMITING -or- HEMATOMA

Pediatric GCS 15

4-Eyes opening spontaneously
5-Smiles, oriented to sounds, follows objects, interacts
6-Infant moves spontaneously or purposefully


Psychiatry

At this time there is no evidence of a non-behavioral medical emergency.


AMA Discharge

The benefits of staying in the ED or hospital (diagnosis and treatment of symptoms and underlying disease) and risks of leaving against medical advice (missed diagnosis of disease, and/or pain, temporary and/or permanent physical or mental disability, and/or death) were discussed with the patient and the family members.  Alternative diagnostic and treatment options were also discussed in the usual and customary manner.

The patient declined further evaluation and/or treatment and elected to leave.  At time of AMA discharge the patient was GCS 15, AAOx3,  and ambulated without difficulty.  Based on my clinical evaluation the patient was competent and had capacity to make this decision.

The patient was also advised that if they changed their mind they could return to the ED at any time for continued medical care.


Chest Pain

After interviewing and examining this patient and reviewing their vital signs, EKG, imaging studies, and laboratory testing I cannot identify any serious or life-threatening etiology for their chest pain.  I've considered serious and life threatening diagnoses such as tension pneumothorax, aortic dissection, acute coronary syndrome, aortic aneurysm, pulmonary embolism, cardiac tamponade, and esophageal injury but none of these diagnoses are supported by any of our findings here today.  I feel that they are safe to be discharged home with close follow up and I've discussed reasons to return to the ER, such as a change in the character or intensity of their chest pain or shortness of breath or other concerning or new symptoms, with the patient.


Aortic Dissection

Healthy appearing, non-Marfanoid patient that denies tearing CP radiating to back

BP was equal in B/L UE and pulses were equal B/L UE and LE, no aortic murmur or focal neuro deficits were noted


SAH

Healthy appearing, non-Marfanoid with normal speech, AAO x 3, GCS 15, supple neck, and no meningismus or focal neurologic deficits

Not a sudden onset headache and not worst of life


Wound Care

No foreign bodies were noted during exploration or during copious high-pressure irrigation of the wound.

The patient and/or their family was informed of the following: there will be the formation of a scar after repair of their wound, direct sunlight to the wound should be avoided for at least 6 months to maximize cosmetic healing of the wound, the patient should have a wound check in 48 hours with their primary care doctor or return to the ER if they have no primary care doctor, and that the patient should return to the ER immediately if signs or symptoms of infection occur such as pain, redness, drainage, swelling, or fever.

The patient and/or their family verbally acknowledged understanding the above information.


Ultrasound

I performed and interpreted a bedside ultrasound in the ED.


EKG

Rate
Rhythm
PR - normal duration
QRS - normal duration
QT - normal duration
Axis - normal
No STE/STD
No Brugada
No Wellens
No Delta wave
Not a STEMI



Smoking

I discussed the risks of tobacco use and the benefits of quitting with the patient.   Increased risk for, and exacerbation of, diseases such as cancer, coronary artery disease, and COPD were discussed.  All questions were answered and the National Quitline was suggested to the patient.  This counseling was at an intermediate level and lasted between 3 and 10 minutes.

Tobacco is the #1 actual cause of death in the United States
Tobacco smoke contains poisons - arsenic, ammonia, and radioactive polonium
Tobacco damages your lungs so you are at a higher risk of pneumonia and bronchitis
Tobacco causes cancers in all parts of your body
Secondhand smoke harms everyone around you and gets in your clothes - so even if you smoke outside the house the smoke gets inside on your clothes and hurts others too