Scenario 3
HISTORY
A 22-year-old African American male comes to the ED with pain due to sickle-cell disease and requests pain medicine. He has never come to this ED before; he usually goes to the one across town, but he “cannot be bothered with those docs because they never give enough pain medicine.” When asked how much pain he has, he states it is a 15/10. The patient is writhing in pain. The doctor assesses the patient and addresses the need for pain control.
PAST MEDICAL HISTORY
Sickle-cell disease, pneumonia. NKDA.
Family history: Sickle-cell trait, hypertension.
Social history: None.
REVIEW OF SYSTEMS
Painful extremities. No fever. No chest pain. No respiratory distress.
PHYSICAL EXAMINATION
GENERAL: Patient writhing in pain.
VITAL SIGNS: Temperature 98.6 ºF, heart rate 110, respiration rate 20, blood pressure 135/80.
HEENT: EOMI. PERRL. Clear TM.
CARDIORESPIRATORY: Sinus tachycardia, normal S1/S2, no murmurs, rubs or gallops. Lungs: CTA bilaterally.
ABDOMEN: Soft, nondistended, diffusely tender.
EXTREMITIES: No clubbing, cyanosis, edema. Pain everywhere.
NEUROLOGIC: Grossly intact.
ASSESSMENT
Sickle-cell crisis.
PLAN
The patient’s painful crisis was appropriately treated with an oral dose of Demerol. There was no fever and no perceived infection. Consequently, no labs were obtained. The patient was new to this ED, and the physician patient interaction was appropriate. The patient was discharged home on oral pain medication and told to follow up as needed.
Determine the level for the number and complexity of the problems addressed at the encounter in Scenario 3.
A.Minimal
B. Low
C. Moderate
D. High
Determine the level for the amount and/or complexity of data to be reviewed and analyzed in Scenario 3.
A. Minimal or None
B. Limited
C. Moderate
D. Extensive
Determine the level for the risk of complications and/or morbidity or mortality of patient management in Scenario 3.
A.Minimal
B. Low
C. Moderate
D. High
Determine the level of medical decision making for Scenario 3.
A. Straightforward
B. Low
C. Moderate
D. High
