ESI practice thread

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.

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)

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.

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."

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.

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.

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.

*clap*

Thankfully OPSI/OPSS has a crazy low incidence. But because it's so rare, all the more reason to stay sharp and not miss it. An easy 2 even if it's just a viral cold in the end.

Agree. He is officially having a major problem until proven otherwise!! I was just about to say -

Wait, did this guy get bit by a dog a couple of days ago and just decide that information wasn't relevant when he checked in??

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.

Good one. I would have made this an esi 5, but didn't know removal of part of ths spleen could pose such a potential problem. I'll now be on the look out for this!