ESI practice thread - page 9

I am starting this tread for people to post scenarios (easy or hard) and for others to say how they would triage this patient according to ESI and their rationale for doing so. I think we can learn a... Read More

  1. by   ~♪♫ in my ♥~
    Quote from Lev <3
    35 y.o. female comes in with c/o of chills, malaise, sore throat, right neck/ear tenderness x4 days. "It hurts to swallow and I can't open my mouth all the way." VS as follows T: 38.5, HR: 97, BP: 107/64, RR: 18, SpO2: 98% on room air. Denies breathing difficulties.
    Elevated T and HR, w/ suspected source of infection meets SIRS criteria and I'd probably make her an ESI 2 and, at one facility, order a stat CBC, C7, and lactate to be drawn within 10 minutes.

    If she looked good and had an unremarkable exam, I might make her a 3 but not a 4... at a minimum she'll get labs, possibly XR/CT neck, likely fluids.
  2. by   Lev <3
    Also may have muffled voice with the peritonsillar abscess.
  3. by   ~♪♫ in my ♥~
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  4. by   canoehead
    Quote from JKL33
    Well, spontaneous pneumo. If he's stable I say 2.
    I would go with 3.
    Mild SOB, and stable vitals. I would not use my last bed for him, he could stay that way for days. Our protocol allows us to order a chest film though, and he could be bumped up quickly if need be. Maybe I'm ruined by Canadian healthcare, we can have 3s waiting 3-4 hours, and I would probably have a sicker person waiting awhile.
  5. by   canoehead
    Quote from amzyRN
    I have another one. A 37-year-old female comes to the widow at triage huffing and puffing, can't catch her breath, is able to say she has asthma and her inhalers aren't working. Her respiratory rate is about 35.
    Sit her down, take vitals, verbal reassurance, lung sounds, talk about her history. She may be a 2 and need nebs, she may be just SOB with exertion, and a 3, or she might be hyperventilating with anxiety.
  6. by   canoehead
    Quote from Lev <3
    Here's one.

    Two weak old infant. Fever of 102. VS otherwise stable.
    A 2. A 1 if they look in the least sick (color, work of breathing, lethargy)
  7. by   emergencynursy
    We usually do. Most of our psych patients and homocidal/suicidal. Even if they're frequent flyers, and they're just there for the sandwiches, they're still a Level 2. The only psych we don't triage as Level 2 is someone who is having anxiety or depression w/o SI/HI.
  8. by   ~♪♫ in my ♥~
    Walk-in pt: 55 YO guy with a history of chronic problems controlled by meds (htn, dm, etc) arrives saying, "I need a new scrip for Norco. I lost mine and I can't get another one for 8 days. I have chronic back pain and it's killing me." The pt lost the meds 3 days ago.

    The patient denies everything else including saddle paresthesia and urinary/fecal retention/incontinence. A&Ox4, abdomen is soft and nontender, no discernible work of breathing, no CVA tenderness, skin PWD.

    VS: 171/105, p153, r18, t36.8

    Prior to ESI, the patient again denies cp, sob, palpitations, dizziness, blurry vision, fevers, chills, n/v/d, dysuria, and abd pain. Explicitly repeats, "I just need a new scrip."
  9. by   JKL33
    Well, it's pretty tempting to make him an ESI 5 since his V/S are consistent with opiate withdrawal and he has no other complaints. But...with a HR in the 150's it's just not good triaging (IMO) to not recognize that there could be a different cause, cardiac, infectious, or DM-related come to mind; there are plenty of ddx in middle-aged male w/ other chronic conditions; opiate abuse vs malingering for financial gain - which is important, since if he's not actually abusing opiates his HR is more worrisome. He could use a 12-lead and a few labs to start.

    Since HE has no c/o and the physical assessment (other than V/S) is apparently not too impressive, I'll say....ESI 3, and can make a case for ESI 2. But not ESI 5 IMO.
  10. by   Pixie.RN
    Quote from KindaBack
    Walk-in pt: 55 YO guy with a history of chronic problems controlled by meds (htn, dm, etc) arrives saying, "I need a new scrip for Norco. I lost mine and I can't get another one for 8 days. I have chronic back pain and it's killing me." The pt lost the meds 3 days ago.

    The patient denies everything else including saddle paresthesia and urinary/fecal retention/incontinence. A&Ox4, abdomen is soft and nontender, no discernible work of breathing, no CVA tenderness, skin PWD.

    VS: 171/105, p153, r18, t36.8

    Prior to ESI, the patient again denies cp, sob, palpitations, dizziness, blurry vision, fevers, chills, n/v/d, dysuria, and abd pain. Explicitly repeats, "I just need a new scrip."
    I hate these! lol. Not because it's probably opiate withdrawal, but because they have a 5-worthy complaint with bad vitals. I agree with JKL33. The HR and BP (though asymptomatic with that BP) are concerning. He's going to be at least a 3.
  11. by   amzyRN
    Quote from KindaBack
    Walk-in pt: 55 YO guy with a history of chronic problems controlled by meds (htn, dm, etc) arrives saying, "I need a new scrip for Norco. I lost mine and I can't get another one for 8 days. I have chronic back pain and it's killing me." The pt lost the meds 3 days ago.

    The patient denies everything else including saddle paresthesia and urinary/fecal retention/incontinence. A&Ox4, abdomen is soft and nontender, no discernible work of breathing, no CVA tenderness, skin PWD.

    VS: 171/105, p153, r18, t36.8

    Prior to ESI, the patient again denies cp, sob, palpitations, dizziness, blurry vision, fevers, chills, n/v/d, dysuria, and abd pain. Explicitly repeats, "I just need a new scrip."
    ESI 2 if the heart rate is accurate, just in case it was something high risk. HR in the 150s at rest is worrisome.
  12. by   Euro_Sepsis
    Walk-in: 26M with nonspecific flu-like symptoms for 2-3 days. Vitals are all normal. Only history is a partial splenectomy a year or two ago.
  13. by   Pixie.RN
    Quote from Euro_Sepsis
    Walk-in: 26M with nonspecific flu-like symptoms for 2-3 days. Vitals are all normal. Only history is a partial splenectomy a year or two ago.
    Immediate full-court press for sepsis. 50 percent mortality rate in this population! Bonus points if you know what OPSI stands for.

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