Practice Cases

1. "I was taking my contacts out last night, and I think I scratched my cornea,"
reports a 27-year-old female. "I'm wearing these sunglasses because the light
really bothers my eyes." Her right eye is red and tearing. She rates her pain as
6/10. Vital signs are within normal limits.
2. EMS presents to the ED with an 18-year-old female with a suspected
medication overdose. Her college roommates found her lethargic and "not
acting right," so they called 911. The patient has a history of depression. On
exam, you notice multiple superficial lacerations to both wrists. Her
respiratory rate is 10, and her SpO2 on room air is 86 percent.
3. EMS arrived with an unresponsive 19-year-old male with a single self-
inflicted gunshot wound to the head. Prior to intubation, his Glasgow Coma
Scale score was 3.
4. "I ran out of my blood pressure medicine, and my doctor is on vacation. Can
someone here write me a prescription?" requests a 56-year-old male with a
history of HTN. Vital signs: BP 128/84, HR 76, RR 16, T 97°F.
5. A 41-year-old male involved in a bicycle accident walks into the emergency
department with his right arm in a sling. He tells you that he fell off his bike
and landed on his right arm. His is complaining of pain in the wrist area and
has a 2-centimeter laceration on his left elbow. "My helmet saved me," he tells
you.
6. A 32-year-old female presents to the emergency department complaining of
shortness of breath for several hours. No past medical history, +smoker. Vital
signs: RR 32, HR 96, BP 126/80, SpO2 93% on room air, T 98.6°F. No allergies,
current medications include vitamins and birth control pills.
7. "I just turned my back for a minute," cried the mother of a 4-year-old. The
child was pulled out of the family pool by a neighbor who immediately
administered mouth-to-mouth resuscitation. The child is now breathing
spontaneously but continues to be unresponsive. On arrival in the ED, vital
signs were: HR 126, RR 28, BP 80/64, SpO2 96% on a non-rebreather.
8. A normal healthy 7-year-old walks into the emergency department
accompanied by his father, who reports that his son woke up complaining of a
stomach ache. "He refused to walk downstairs and is not interested in eating
or playing." The child vomits at triage. Vital signs: T 100.4°F, RR 22, HR 88, BP
84/60, SpO2100%. Pain 6/10.
9. A 6-year-old male tells you that he was running across the playground and
fell. He presents with a 3-centimeter laceration over his right knee. Healthy,
no medications and no allergies, immunizations are up to date.
10. "I slipped on the ice, and I hurt my wrist," reports a 58-year-old female with a
history of migraines. There is no obvious deformity. Vital signs are within
normal limits, and she rates her pain as 5/10.
11. A 4-year-old female is transported to the ED following a fall off the jungle gym
at a preschool. A fall of 4 feet. A witness reports that the child hit her head and
was unconscious for a couple of minutes. On arrival you notice that the child
is crying and asking for her mother. Her left arm is splinted. Vital signs: HR
162, RR 38.
12. A 60-year-old man requests to see a doctor because his right foot hurts. On
exam the great toe and foot skin is red, warm, swollen, and tender to touch.
He denies injury. past medical history includes type 2 diabetes, and psoriasis.
Vital signs: T 99.4°F, RR 18, HR 82, BP 146/70, SpO2 99%.
13. A 52-year-old female requests to see a doctor for a possible urinary tract
infection (UTI). She is complaining of dysuria and frequency. She denies
abdominal pain or vaginal discharge. No allergies, takes vitamins, and has no
significant past medical history. Vital signs: T 97.4°F, HR 78, RR 14, BP
142/70.
14. "I called my pediatrician, and she told me to bring him in because of his
fever," reports the mother of a 2-week-old. Vital signs: T 101°F, HR 154, RR
42, SpO2 100%. Uncomplicated, vaginal delivery. The baby is acting
appropriately.
15. "My right breast is so sore, my nipples are cracked, and now I have a fever. Do
you think I will have to stop nursing my baby?" asks a tearful 34-year-old
female. She is 3 months post partum and has recently returned to work
parttime. Vital signs: T 102.8°F, HR 90, RR 18, BP 108/60, pain 5/10. No past
medical history, taking multivitamins, and is allergic to penicillin.
16. Paramedics arrive with a 16-year-old unrestrained driver who hit a tree
while traveling at approximately 45 miles per hour. The passenger side of the
car had significant damage. The driver was moaning but moving all
extremities when help arrived. His initial vital signs were BP 74/50, HR 132,
RR 36, SPO2 99%, T 98.6°F.
17. EMS arrives with a 45-year-old woman with asthma who has had a cold for
week. She started wheezing a few days ago and then developed a cough and a
fever of 103. Vital signs: T 101.6°F, HR 92, RR 24, BP 148/86, SpO2 97%.
18. "I have an awful toothache right here," a 38-year-old male tells you as he
points to his right lower jaw. "I lost my dental insurance, so I haven't seen a
dentist for a couple of years." No obvious swelling is noted. Vital signs are
within normal limits. Pain 9/10.
19. "I think I have food poisoning," reports an otherwise healthy 33-year-old
female. "I have been vomiting all night, and now I have diarrhea." The patient
admits to abdominal cramping that she rates as 5/10. She denies fever or
chills. Vital signs: T 96.8°F, HR 96, RR 16, BP 116/74.
20. "My migraine started early this morning, and I can't get it under control. I just
keep vomiting. Can I lie down somewhere?" asks a 37-year-old female. Past
 medical history migraines, no allergies. Pain 6/10, T 98°F, RR 20, HR 102, BP
118/62, SpO2 98%.
21. "I cut my finger trying to slice a bagel," reports a 28-year-old healthy male. A
2-centimeter laceration is noted on the left first finger. Bleeding is controlled.
Vital signs are within normal limits. His last tetanus immunization was 10
years ago.
22. "The smoke was so bad; I just couldn't breathe." reports a 26-year-old female
who entered her burning apartment building to try to rescue her cat. She is
hoarse and complaining of a sore throat and a cough. You notice that she is
working hard at breathing. History of asthma; uses inhalers when needed. No
known drug allergies. Vital signs: T 98°F, RR 40, HR 114, BP 108/74.
23. "I'm 7 weeks pregnant, and every time I try to eat something, I throw up,"
reports a 27-year-old female. "My doctor sent me to the emergency
department because he thinks I am getting dehydrated. T 97°F, RR 18, HR
104, BP 104/68, SpO2 99%. Pain 0/10. Lips are dry and cracked.
24. "I have this aching pain in my left leg," reports an obese 52-year-old female.
"The whole ride home, it just ached and ached." The patient tells you that she
has been sitting in a car for the last 2 days. "We drove my daughter to college,
and I thought it was the heat getting to me." She denies any other complaints.
Vital signs: BP 148/90, HR 86, RR 16, T 98°F.
25. EMS arrives with an 87-year-old male who fell and hit his head. He is awake,
alert, and oriented and remembers the fall. He has a past medical history of
atrial fibrillation and is on multiple medications, including warfarin. His vital
signs are within normal limits.
26. "I have this rash in my groin area," reports a 20-year-old healthy male. "I
think it's jock rot, but I can't get rid of it." Using over the counter spray. No
known drug allergies. Vital Signs: T 98°F, HR 58, RR 16, BP 112/70.
27. EMS arrives with a 17-year-old restrained driver involved in a high-speed
motor vehicle crash. The patient is immobilized on a backboard and is
complaining of abdominal pain. He has multiple lacerations on his left arm.
Vital signs prior to arrival: BP 102/60; HR 86, RR 28, SpO2 96%.
28. "I just need another prescription for pain medication. I was here 10 days ago
and ran out," a 27-year-old male tells you. "I hurt my back at work, and it's
still bothering me." Denies numbness, tingling, or bladder or bowel issues.
Vital signs are within normal limits. Pain 10+/10.
29. EMS arrives with a 32-year-old female who fell off a stepladder while cleaning
her first-floor gutters. She has an obvious open fracture of her right lower leg.
She has +2 pedal pulse. Her toes are warm, and she is able to wiggle them.
Denies past medical history medications, or allergies. Vital signs are within
normal limits for her age.
 30. The medical helicopter is en route to your facility with a 16-year-old male
who was downhill skiing and hit a tree. Bystanders report that he lost control
and hit his head. He was intubated at the scene and remains unresponsive.

Assign an ESI level to each of these patients.

Level Patient

1. A 62-year-old with CPR in progress.

_________

2. A 53-year-old with 30% body surface are burn.

_________

3. A 22-year-old who needs a work note.

_________

4. A 12-year-old with an earache.

_________

5. A 45-year-old involved in high speed motor vehicle collision, BP 120/60 HR72, RR.
_________ 18.

6. An unresponsive 14-year-old. EMS tells you he and his friend had been "doing
_________ shots."

Questions
Read each case and determine whether the patient meets the criteria for ESI level 2.
Justify your decision.

1. A 40-year-old male presents to triage with vague, midsternal chest discomfort,

occurring intermittently for one month. This morning, he reports a similar episode,
which has now resolved. Currently complains of mild nausea, but feels pretty good.
Medical history: Smoker. He is alert, with skin warm and dry, does not appear to be
in any distress.
2. A 22-year-old female on college break presents to the triage desk complaining of
sudden onset of feeling very sick, severe sore throat, and feeling "feverish." She is
dyspneic and drooling at triage, and her skin is hot to touch.

3. A 68-year-old male brought in by his wife for sudden onset of left arm weakness,
slurred speech, and difficulty walking. Symptoms began 2 hours prior to arrival.
Past medical history: Atrial fibrillation. Meds: Lanoxin. The patient is awake,
oriented, mildly short of breath. Speech is slurred; right-sided facial droop is
present. Left upper-extremity weakness noted with 2/5 muscle strength.

4. A 60-year-old male complains of sudden loss of vision in the left eye that morning.
Patient denies pain or discomfort. Past medical history: CAD, HTN. The patient is
slightly anxious but no distress.

5. A 22-year-old female with 10/10 abdominal pain for two days. Denies nausea,
vomiting, diarrhea, or urinary frequency. Her heart rate is 84 and she is eating ice
cream.

6. A 70-year-old female with her right arm in a cast is brought to triage by her
daughter. The daughter states that her mother fell yesterday and fractured her arm.
The patient is complaining of pain. Daughter states, "They put this cast on yesterday,
but I think it's too tight." Daughter reports her mother has been very restless at
home and thinks her mother is in pain. Patient has a history of Alzheimer's disease.
The patient is confused and mumbling (at baseline per daughter); face flushed. She
is unable to provide verbal description of her complaints. Her right upper extremity
is in a short arm cast; digits appear tense, swollen and ecchymotic. Nail beds are
pale; capillary refill delayed. Patient is not wearing a sling.

7. An 8-month-old presents with fever, cough, and vomiting. The baby has vomited
twice this morning; no diarrhea. Mom states the baby is usually healthy but has "not
been eating well lately." Doesn't own a thermometer, but knows the baby is "hot"
and gave acetaminophen two hours prior to arrival. The baby is wrapped in a
blanket, eyes open, appears listless, skin hot and moist, sunken fontanel.
Respirations are regular and not labored.

8. A 34-year-old male presents to triage with right lower quadrant pain, 5/10, all
day. Pain is associated with loss of appetite, nausea and vomiting. Past medical
history: None. The patient appears in moderate discomfort, skin warm and dry,
guarding abdomen.

9. A 28-year-old male arrives with friends with a chief complaint of a scalp

laceration. Patient states he was struck in the head with a baseball bat one hour
prior to arrival. Friends state he "passed out for a couple of minutes." Patient
complains of headache, neck pain, mild nausea, and emesis x 1. Patient looks pale,
but is otherwise alert and oriented to person, place, and time. There is a 5-cm
laceration to the scalp near his left ear with bleeding controlled.

10. A 28-year-old male presents with a chief complaint of tearing and irritation to
the right eye. He is a construction worker and was drilling concrete. He states "I feel
like there is something in my eye" and reports "irrigated the eye several times but it
doesn't feel any better." Patient appears in no severe distress; however, he is
continually rubbing his eye. Right eye appears red, irritated, with excessive tearing.

11. A 40-year-old male is brought in by his son. He is unable to ambulate due to foot
and back pain. Patient states he fell approximately 10 feet off of a ladder and is
complaining of foot and back pain. States he landed on both feet and had immediate
foot and back pain. Denies loss of consciousness/neck pain. No other signs of
trauma noted. The patient appears pale, slightly diaphoretic, and in mild distress. He
rates his pain 6/10. Patient is sitting upright in a wheelchair.

12. A 12-year-old female is brought to triage by her mother who states her daughter
has been weak and vomiting for three days. The child states she "feels thirsty all the
time and her head hurts." Vomited once today. Denies fever, abdominal pain, or
diarrhea. No significant past medical history. The child is awake, lethargic, and
slumped in the chair. Color is pale, skin warm and dry.

13. A 40-year-old male presents to triage with a gradual increase in shortness of

breath over the past two days associated with chest pain. Past medical history: colon
cancer. He is in moderate respiratory distress, skin warm and dry.

14. A 60-year-old male presents with complaint of dark stools for one month with
vague abdominal pain. Past medical history: None. Pulse is tachycardic at a rate of
140 and he has a blood pressure of 80 palpable. His skin is pale and diaphoretic.

15. EMS arrives with a 25-year-old female with the sudden onset of significant
vaginal bleeding, with 9/10 abdominal pain. The patient is 7 months pregnant. BP
92/pal, HR 130.