Jump to content

"it's probably nothing"-fast track disasters

Recommended Posts

try to guess the ADMITTING dx for each of these recent fast track complaints. let's see who can get them all first. some are easy, some aren't....gotta stay on your toes even in fast track folks....

 

diabetic 50 yo m with "shoulder pain"

85 year old htn male with atraumatic "neck pain"

30 yr old fe on o.c.'s with "blurry vision"

75 year old male with worsening "leg pain" x weeks

35 yr old fe with btl with "bad gas pains and dizzyness"

17 year old fem with "yeast infection and fever"

18 yr old male iddm pt with" new onset asthma"

50 yr old morbidly obese poorly controlled htn m with "heartburn"

45 yr old fe "bleeding gums"

22 yr old fe "taking LOTS of otc pain meds for menstrual cramps, now n/v"

  • Upvote 1

Share this post


Link to post
Share on other sites
try to guess the ADMITTING dx for each of these recent fast track complaints. let's see who can get them all first. some are easy, some aren't....gotta stay on your toes even in fast track folks....

 

75 year old male with worsening "leg pain" x weeks

intermittent claudication

 

as a 20 yr pre-PAS this is the only one im willing to guess at. i work on a tele floor and this is something that i hear about alot. usually caused by build up of plaque in the ateries of the pts legs. so the legs do not receive adequate amts of 02. the pain is felt after certain time of physical activity and usually goes away after pt rests for a while. these pts usually go for a peripheral ateriogram and have a ballon angioplasty. this is all i know. im guessing stents may also be placed.

 

educate me!!!!!!!!! :)

Share this post


Link to post
Share on other sites

hmm, let me take a shot

50 yo diabetic 'shoulder' pain- AMI or cholecysitis, probably AMI / refered pain to the shoulder.

85 yo atraumatic neck pain- CVA, rupture of the spinal artery, or meningitis, the hx of HTN leads me to believe it is more a vascular problem

30 yo female on oc with blurry vision- tough one, is she a smoker? could be CVA, aneurysm of the anterior cereberal artery, could need new glasses or pituitary adenoma?

 

22 yo female "taking lots of OTC meds for menstrual cramps, now n/v"- etopic pregnancy or hepatotoxicity due to meds, could be both.

Share this post


Link to post
Share on other sites
try to guess the ADMITTING dx for each of these recent fast track complaints. let's see who can get them all first. some are easy, some aren't....gotta stay on your toes even in fast track folks....

 

diabetic 50 yo m with "shoulder pain" AMI

85 year old htn male with atraumatic "neck pain"

30 yr old fe on o.c.'s with "blurry vision" micro emboli

75 year old male with worsening "leg pain" x weeks slow AAA leak

35 yr old fe with btl with "bad gas pains and dizzyness" ectopic, ruptured ectopic

17 year old fem with "yeast infection and fever"PID

18 yr old male iddm pt with" new onset asthma"

50 yr old morbidly obese poorly controlled htn m with "heartburn"MI

45 yr old fe "bleeding gums" ITP

22 yr old fe "taking LOTS of otc pain meds for menstrual cramps, now n/v"PUD, GI bleed

 

Those are the best I could come up with... :p

Share this post


Link to post
Share on other sites

correct so far

#1 ami

#2

#3 ischemic stroke

#4 acute arterial occlusion.pale/cold pulseless leg

#5 ruptured ectopic

#6 pid with disseminated gonnococcal sepsis

#7

#8

#9

#10 getting close with hepatotoxicity-which meds?

 

how about 2/7/8/9?

Share this post


Link to post
Share on other sites

85 year old htn male with atraumatic "neck pain"- I dont know.

 

18 yr old male iddm pt with" new onset asthma"- DKA, pt is breaking down fats, causing a shift in the pH of the blood, leading to hyperventilation to balance the pH

50 yr old morbidly obese poorly controlled htn m with "heartburn"-AAA- (poorly controled HTN increases risk for aortic blowout)

45 yr old fe "bleeding gums"- leukemia, AML

22 yr old fe "taking LOTS of otc pain meds for menstrual cramps, now n/v"- ibuprofen OD (hepatic metabolism, excreted through kid), if she really did take a LOT, she probably combined it w/ APAP.

Share this post


Link to post
Share on other sites
Guest nanci31

#2- possible meningitis

#8- possible acute mi

#9- pericarditis, immune compromised

#10- renal/ liver problems

Share this post


Link to post
Share on other sites
85 year old htn male with atraumatic "neck pain"- I dont know.

 

18 yr old male iddm pt with" new onset asthma"- DKA, pt is breaking down fats, causing a shift in the pH of the blood, leading to hyperventilation to balance the pH

50 yr old morbidly obese poorly controlled htn m with "heartburn"-AAA- (poorly controled HTN increases risk for aortic blowout)

45 yr old fe "bleeding gums"- leukemia, AML

22 yr old fe "taking LOTS of otc pain meds for menstrual cramps, now n/v"- ibuprofen OD (hepatic metabolism, excreted through kid), if she really did take a LOT, she probably combined it w/ APAP.

 

right on all counts:

#7 dka with kussmaul resp. random glucose>800, abg: ph =7.0

#8 dissecting aaa

#9 new dx aml with platelet count < 1500 total and wbc =78,000 all blasts

#10 acute tylenol toxicity from taking 2-3 gm tylenol qid for several days in several different products

 

how about #2? the guy said it was the worst pain he had ever had(worse than a gsw in ww2) and it came on suddenly. he ended up seeing a neurosurgeon for this dx found on ct( could have been found on lp also but not done because ct +)

Share this post


Link to post
Share on other sites

e-

 

more!

tho common things are truely common, the reason i harp that the most experienced and seasoned clinicians should be in both triage and -if you have it- fast-track/walk-in/minor care is exactly the cases that you presented.

 

on point exactly.

 

v/r

rc

Share this post


Link to post
Share on other sites
Guest nanci31

Thanks EMED-PA, you make me think. I have not even started school yet. Only two mos until school starts!

Share this post


Link to post
Share on other sites

1. Acute MI or septic shoulder

2.

3. Spinal Stenosis or Peripheral Vascular occlusive disease

4. I'd rule out ectopic

5. PID

6. Metastatic Testicular Cancer or maybe even Cystic Fibrosis

7. AMI or PE

8. Thyrombocytopenia (ITP, TTP, Vaculitis)

9. Tylenol overdose with fulminant hepatic failure ensuing

Share this post


Link to post
Share on other sites
e-

 

more!

tho common things are truely common, the reason i harp that the most experienced and seasoned clinicians should be in both triage and -if you have it- fast-track/walk-in/minor care is exactly the cases that you presented.

 

on point exactly.

 

v/r

rc

We rotate all of our clinicians through fast track, intermediate, trauma, and higher acuity positions so we all stay sharp. also no one gets bored.....

Share this post


Link to post
Share on other sites

25 year old male triaged as "minor mva, multiple complaints"

"minor mva" is relative I guess. to me 65 mph multiple rollover into the center divider is not a minor mva. especially when your head impacts multiple parts of the car and the medics cut you out of the car.....the pt in question then refused transport despite head, chest and neck pain on scene. taken to er by friend who he called from scene. triaged to fast track.....(!@#$%^&*)

waits> 3 hrs to be seen then I have to call a trauma alert on this guy, do the full c-spine deal, 2 lg bore lines, etc

workup includes ct head and neck as well as several plain films. initial c-spine films with prevertebral swelling at c-2 level, confirmed as fx on ct. handed off to trauma team neuorosurgeon at that point. disposition unknown at this point.....

it's all about the hx folks. very few multiple rollovers are that minor.....happens, just not often.....

Share this post


Link to post
Share on other sites

us older guys can remember when - before belts/straps and bags- that sorta accident was fatal 90% of the time, or at least physically devestating or deforming.

 

Triage fails, in my experience, 15% of the time.

 

The only safety net is the end user (the doc/pa), who has to not be lulled into the circular argument : he is in fast-tract/ walk-in/minor care, ergo: he cannot be sick!

 

drives me nuts as well, e-

davis

Share this post


Link to post
Share on other sites

My experience with trauma is that at most trauma centers you typically have a 20% undertriage as well as a 20% over-triage.

 

E- just wondering if your facility does PI on cases like this where the mechanism alone indicates the need for, at least, an urgent ER eval as opposed to fast track. Is their "education" for the nursing staff regarding the decision to fast track the pt?

Share this post


Link to post
Share on other sites
My experience with trauma is that at most trauma centers you typically have a 20% undertriage as well as a 20% over-triage.

 

E- just wondering if your facility does PI on cases like this where the mechanism alone indicates the need for, at least, an urgent ER eval as opposed to fast track. Is their "education" for the nursing staff regarding the decision to fast track the pt?

 

if the nurse in question has taken a good hx they would have been trauma flagged just on mechanism. he was just being lazy......

note just said" minor, mva, neck pain".

I agree with the 20% over/under idea....

Share this post


Link to post
Share on other sites

25 yr old male 2 days s/p motorcycle accident with "increasing chest and abd discomfort"....was wearing hemet when he laid his bike down, catching handlebar in center of abd.....

exam:young diaphoratic male clutching abd

vs p 96 r 22 bp 110/70 t 37 sao2 96

heent:ncat

neck supple, nt

chest: lg abrasions entire anterior chest and abd, significant tenderness with compression/ringing chest, lungs clear

abd: rigid, dec. bs throughout, tender throughout

pelvis: stable, nt

ext: abrasions, otherwise unremarkable

neuro intact, nonfocal

 

ed course:

minute 1-2 trauma alert, surgeon notification, 2 iv's with lab draws, o2

min 3-4 portable cxr : free air under r diaphragm, no obvious rib fx, no ptx or hemothorax

min 5-7 ct abd: perfed bowel with bowel contents(that's right, poop) and blood all over the abd

min 10 transfer to o.r. for emergent lap(surgeon not happy about it but oh well.....)

on way to o.r. pt becomes hypotensive requiring pressor support

benign o.r. course, does well, admitted to surgical service for prolonged admission and recovery.......

was in the o.r. before 1st set of labs back....cbc with H+H 7/21.....

this guy was a no brainer trauma alert from the moment I entered the room.I actually thought he had a slow spleen or liver bleed but bowel rupture did the trick too apparently..... that nurse is no longer doing triage.....mind you this was my second pt of the day and I was still on cup of coffee #1...and pt #1 was a simple lac that I could( and probably did) suture in my sleep....talk about a wake up.....

Share this post


Link to post
Share on other sites

dammmn

surprised his pulse wasn't up.

e-:

what is your trauma CT abd protocol?

 

we are having discussions with new radiologist who feels 64 secter CTs sensitive enough ameliorate oral contrast..wants to give -if anythingt- water.

older radiologists hate "quick looks" and want oral + IV...

 

did PCXR show the free air?

 

v/r

 

rc

Share this post


Link to post
Share on other sites

iv contrast only for initial trauma ct. if they are looking for something subtle later on in a stable pt. they may add oral or rectal contrast.

yup, extensive r sided free air on initial cxr.

I'm guessing that probably was a fairly high pulse for this guy. he was a skinny endurance athlete in great shape and probably has a resting pulse in the low 50's. he looked bad enough on initial presentation that my (fairly astute) nurse(NOT the one from triage...) pulled me away from the aforementioned 1st cup of coffee before even finishing taking his vitals....didn't even leave the room...I just heard" emedpa, I need you in here now" and that was enough to get me moving......

also on the subject of ct's....we currently use an oral+iv protocol for appy and diverticulitis studies and are doing a study of iv + rectal only. seems to be just as sensitive and saves a lot of time.....hope it pans out

Share this post


Link to post
Share on other sites

42 yr female with severe MR sent o fast track with "swollen nodes"

 

NO VITALS ON TRIAGE and pt made to wait in waiting room untill the freaking cleaning lady told me there was a woman who looked like she was choking.

 

This pt. was with a transport worker who new nothing. A note from her PCP (an NP) from three days prior:

 

S: unable to attain vitals

O: no sign of infection

A/P: dx sinusitis dc with z pack

 

no ****---that was her note.

 

long story short--ludwigs angina

wbc 34k

temp 103

Po2---48%

 

CT neck/chest showed air from neck deep into mediastinus.

 

sent to surg where they found a three inch chicken bone in her neck that lacerated her esophagus.

 

Nursing home records show "no chicken server in over ten days."

Share this post


Link to post
Share on other sites

Join the conversation

You can post now and register later. If you have an account, sign in now to post with your account.

Guest
Reply to this topic...

×   Pasted as rich text.   Paste as plain text instead

  Only 75 emoji are allowed.

×   Your link has been automatically embedded.   Display as a link instead

×   Your previous content has been restored.   Clear editor

×   You cannot paste images directly. Upload or insert images from URL.


×
×
  • Create New...

Important Information

Welcome to the Physician Assistant Forum! This website uses cookies to ensure you get the best experience on our website. Learn More