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Case: Morning Trouble (adapted from CRICO/Risk Management Foundation, 2005).

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Presentation Transcript
slide1

Case: Morning Trouble

(adapted from CRICO/Risk Management Foundation, 2005)

A 42-year-old uninsured woman, who had not seen a doctor in 20 years, presented to the emergency department (ED) at 7:50 a.m., complaining of chest pain and trouble breathing. She was accompanied by her husband and her son, who helped interpret because English was her second language.

The husband reported that his wife had been experiencing chest pain since 11:00 the prior evening, which she treated with aspirin. In the morning, she had sudden onset of severe chest pain and fainted on her bed.

The patient was first seen by the ED attending and then by a resident. Her initial vital signs were: HR: 107, BP: 146/99, RR:29. Her chest pain was documented as “sudden onset, right-sided, sharp, under the right breast, started while the patient was lying in bed and worse with inspiration, movement, and palpation.” The patient’s medical history was documented by the resident as: “fainting spells, no family history of coronary artery disease or clots, father suffered a stroke.”

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Background

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Time: 00:00:17

slide2

English as a second language

Click on a keyword for more information:

Is there someone with a medical background who can reliably interpret for the patient?

Is English the son’s/husband’s first language?

Was the history documented with the presence of an interpreter other than family members?

Was there any ambiguity in taking the patient’s history?

A 42-year-olduninsured woman, who had not seen a doctor in 20 years, presented to the emergency department (ED) at 7:50 a.m., complaining of chest pain and trouble breathing. She was accompanied by her husband and her son, who helped interpret because English was her second language.

The husband reported that his wife had been experiencing chest pain since 11:00 the prior evening, which she treated with aspirin. In the morning, she had sudden onset of severe chest pain and fainted on her bed.

The patient was first seen by the ED attending and then by a resident. Her initial vital signs were: HR: 107, BP: 146/99, RR:29. Her chest pain was documented as “sudden onset, right-sided, sharp, under the right breast, started while the patient was lying in bed and worse with inspiration, movement, and palpation.” The patient’s medical history was documented by the resident as: “fainting spells, no family history of coronary artery disease or clots, father suffered a stroke.”

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Background

H&P

Test

Consult

Notebook

Incurred cost: $0.00

Time: 00:01:35

slide3

English as a second language

Click on a question for more information

A reliable interpreter with

a medical background is not available.

Is there someone with a medical background who can reliably interpret for the patient?

Is English the son’s/husband’s first language?

Was the history documented with the presence of an interpreter other than family members?

Was there any ambiguity in taking the patient’s history?

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A 42-year-olduninsured woman, who had not seen a doctor in 20 years, presented to the emergency department (ED) at 7:50 a.m., complaining of chest pain and trouble breathing. She was accompanied by her husband and her son, who helped interpret because English was her second language.

The husband reported that his wife had been experiencing chest pain since 11:00 the prior evening, which she treated with aspirin. In the morning, she had sudden onset of severe chest pain and fainted on her bed.

The patient was first seen by the ED attending and then by a resident. Her initial vital signs were: HR: 107, BP: 146/99, RR:29. Her chest pain was documented as “sudden onset, right-sided, sharp, under the right breast, started while the patient was lying in bed and worse with inspiration, movement, and palpation.” The patient’s medical history was documented by the resident as: “fainting spells, no family history of coronary artery disease or clots, father suffered a stroke.”

Toolbox

Background

H&P

Test

Consult

Notebook

Incurred cost: $0.00

Time: 00:02:09

slide4

Test

Blood gases

Chest X-Ray

Blood gases $110

Lab Tests

Blood cultures/ASTBlood gases

AcetoneArteritis (ANA)CBC

CO2

CSFGlucosePotassiumSodiumLiver (SGOT)Liver (SGPT)StoolThyroid

Urinalysis

Studies/Tests

Angiogram

Audiometry

Biopsy

Bone Scan

Cardiac Eval

Cisternogram

CT

EEG

ECG

EMG/NCS

ENG

Evoked Potentials

Genetic Tests

Ischemic Exercise Test

MRA

MRI

Muscle Biochem

Myelogram

Neuropsych Testing

Pap Smear

Pulmonary Function

Schilling Test

SPECT Scan

Tensilon Test

Visual Fields

X-rays

HCO3 26 mEq/L

pH 7.41

pCO2 45mmHg

pO2 80 mmHg

Save in Notebook

Toolbox

Background

H&P

Test

Consult

Notebook

Incurred cost: $110.00

Time: 00:07:42

slide5

Test

ECG

Chest X-Ray

ECG $1,000

Lab Tests

Blood cultures/ASTBlood gases

AcetoneArteritis (ANA)CBC

CO2

CSFGlucosePotassiumSodiumLiver (SGOT)Liver (SGPT)StoolThyroid

Urinalysis

Studies/Tests

Angiogram

Audiometry

Biopsy

Bone Scan

Cardiac Eval

Cisternogram

CT

EEG

ECG

EMG/NCS

ENG

Evoked Potentials

Genetic Tests

Ischemic Exercise Test

MRA

MRI

Muscle Biochem

Myelogram

Neuropsych Testing

Pap Smear

Pulmonary Function

Schilling Test

SPECT Scan

Tensilon Test

Visual Fields

X-rays

Click to enlarge

Save in Notebook

Toolbox

Background

H&P

Test

Consult

Notebook

Incurred cost: $1,110.00

Time: 00:08:54

slide6

Notebook

Chest pain

Shortness of breath

Stroke in family history

Absence of trained interpreter

Age

Aspirin

Gender

Background

Final vital signs

Initial vital signs

H&P

ECG

No cardiac enzymes results

Elevated glucose

X-Rays

Blood gases

Test

Absence of cardiology consult

Consult

slide7

Notebook

Key Student

Chest pain

Shortness of breath

Stroke in family history

Absence of trained interpreter

Age

Aspirin

Gender

Background

Why does the student not consider these high risk?

Final vital signs

Initial vital signs

H&P

ECG

No cardiac enzymes results

Elevated glucose

X-Rays

Blood gases

Test

Absence of cardiology consult

Consult

slide8

User Rating Profile in Case Progression

Profile of Student’s Rating during Case Progression

Cumulative mean rating of risk value accessed

(Scale 1-5)

(High) 5

4

Student 6529

(Moderate) 3

2

What causes the profile to shift?

Baseline

(Low) 1

0

(Start)

Time (seconds)

(End)

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