# Clinical Cases: Disposition and Communication

## Case 1: The High-Risk Discharge - Chest Pain Going Home

### Patient Demographics
- **Age:** 52 years
- **Sex:** Male
- **Occupation:** Accountant

### Chief Complaint
"I had chest pain this morning but it's gone now."

### History of Present Illness
A 52-year-old male presents for evaluation of chest pain that occurred this morning while walking to his car. He describes 10 minutes of substernal pressure that radiated to his left arm, associated with diaphoresis. The pain resolved spontaneously and he "feels fine now." He almost didn't come in but his wife insisted. He has no prior cardiac history but acknowledges he hasn't seen a doctor in years.

### Initial Assessment

**ESI Level:** 2 - Potential ACS despite current symptom resolution

**First Impression:**
- Appearance: Well-appearing, no distress
- Work of breathing: Normal
- Circulation: Normal

**Vital Signs:**
- Heart rate: 78 bpm
- Blood pressure: 142/88 mmHg
- Respiratory rate: 14 breaths/min
- SpO2: 99% on room air
- Temperature: 36.8C
- GCS: 15

### ED Evaluation

**ECG:** Normal sinus rhythm, no ST changes, no prior for comparison

**Serial Troponins:**
- 0 hours: <0.01 ng/mL (negative)
- 3 hours: <0.01 ng/mL (negative)

**Chest X-ray:** Normal

**Basic Labs:** Normal BMP, glucose 118

### Risk Stratification

**HEART Score:**
| Factor | Points | This Patient |
|--------|--------|--------------|
| History | 0-2 | 2 (highly suspicious) |
| ECG | 0-2 | 0 (normal) |
| Age | 0-2 | 1 (45-65) |
| Risk factors | 0-2 | 2 (HTN untreated, sedentary, family hx unknown) |
| Troponin | 0-2 | 0 (negative x2) |
| **Total** | | **5** |

**HEART Score Interpretation:**
- 0-3: Low risk (discharge with follow-up)
- 4-6: Intermediate risk (observation, further testing)
- 7-10: High risk (admission, cardiology)

**Score of 5 = INTERMEDIATE RISK**

### Disposition Decision Process

**Options:**
1. **Admit** for observation and stress testing
2. **Discharge** with expedited outpatient stress test
3. **Observation unit** for accelerated diagnostic protocol

**Factors Favoring Discharge:**
- Negative troponins x2
- Normal ECG
- Symptom-free for hours
- Reliable patient with transportation
- Can obtain stress test within 72 hours

**Factors Favoring Admission:**
- Highly suspicious history
- Intermediate HEART score
- No established care/no prior testing
- Multiple untreated risk factors

### Shared Decision-Making Discussion

**Conversation with Patient:**

"Mr. Johnson, your tests today look normal - your heart enzyme is negative and your ECG is normal. However, your symptoms this morning were concerning for possible angina, which can be a warning sign of blocked heart arteries.

Your risk isn't zero. Based on your story and risk factors, I estimate you have about a 10-15% chance of having a significant heart problem that we haven't found yet.

We have two main options:

**Option 1:** Stay overnight for observation and have a stress test tomorrow. This is the safest approach and lets us evaluate you more thoroughly.

**Option 2:** Go home tonight with a guaranteed stress test within 72 hours. This requires you to take certain precautions and return immediately if symptoms recur.

What questions do you have? What would you prefer?"

**Patient Response:** "I really need to be at work tomorrow for a big deadline. Can I do the outpatient option?"

### High-Risk Discharge Protocol

**Requirements for Safe Discharge:**
1. **Reliable follow-up confirmed:** Stress test scheduled for tomorrow morning (within 24 hours)
2. **Clear return precautions:** Written and verbal
3. **Medication management:** Started on aspirin, prescribed sublingual nitroglycerin
4. **Transportation plan:** Wife can drive if symptoms recur
5. **Documentation:** Thorough, including shared decision-making discussion

### Discharge Instructions (Written and Verbal)

**Return to ED Immediately If:**
- Chest pain or pressure returns
- Pain that doesn't go away within 5 minutes of nitroglycerin
- Shortness of breath
- Sweating with discomfort
- Pain that spreads to arm, jaw, or back
- Dizziness or fainting

**Activity Restrictions:**
- No strenuous activity until cleared by stress test
- No driving until evaluated
- Someone should stay with you tonight

**Medications:**
- Aspirin 81mg daily (started)
- Nitroglycerin 0.4mg SL PRN chest pain (instructions provided)
- Continue any home medications

**Follow-Up:**
- Stress test: Tomorrow 8 AM at Hospital Outpatient Center (confirmed appointment)
- Primary care: Within 1 week for cardiovascular risk management
- Cardiology: Depending on stress test results

### Documentation Requirements

**Critical Elements for High-Risk Discharge:**
1. History and physical documented thoroughly
2. Risk stratification tool documented (HEART score = 5)
3. Test results reviewed (negative troponins, normal ECG)
4. Medical decision-making explained (intermediate risk, shared decision)
5. Alternatives discussed (admission offered)
6. Follow-up confirmed and documented
7. Return precautions documented (reviewed with patient)
8. Discharge instructions given and understood
9. Patient agreement documented

### Outcome

**Day 1 (next morning):**
- Stress test performed: Positive at 6 minutes (ST depression in inferior leads)
- Referred directly to cardiology

**Day 2:**
- Cardiac catheterization: 85% stenosis of RCA
- PCI with stent placed
- Patient did well, discharged day 3

**Teaching Moment:** The system worked - high-risk discharge with appropriate safety net led to timely diagnosis and treatment

### Teaching Points

1. **Risk stratification tools guide decisions:** HEART score, TIMI, GRACE - know and use them
2. **Intermediate risk is the challenge:** Not clear-cut; requires shared decision-making
3. **Shared decision-making is essential:** Document the conversation
4. **Follow-up must be confirmed:** Not "see your doctor" but "your appointment is at..."
5. **Return precautions must be specific:** Written AND verbal, condition-specific
6. **Documentation protects everyone:** If it wasn't documented, it didn't happen
7. **Safety nets catch patients:** Appropriate follow-up caught this patient's disease
8. **Communicate uncertainty:** Patients appreciate honesty about diagnostic limitations

### Clinical Image
![HEART Score Risk Stratification](case_01_image.jpg)

**Image Description:** Infographic displaying the HEART score components (History, ECG, Age, Risk factors, Troponin) with point values for chest pain risk stratification in the emergency department.

**Attribution:** Image adapted from HEART score validation studies. Educational use. Source: https://www.mdcalc.com/heart-score-major-cardiac-events

---

## Case 2: Handoff Communication - The Night Shift Transfer

### Patient Demographics
- **Age:** 78 years
- **Sex:** Female
- **Occupation:** Retired librarian

### Clinical Scenario

**Setting:** It's 7 AM shift change. The night shift physician is handing off to the day shift. Mrs. Williams has been in the ED since 2 AM and needs to be "signed out" for continued care.

### Patient Summary for Handoff

**One-liner:** 78-year-old female with CHF and CKD presenting with 2 days of progressive dyspnea, found to have acute CHF exacerbation with volume overload.

### IPASS Handoff Framework

**I - Illness Severity:**
"Mrs. Williams in Room 12 is SICK but STABLE. She's on BiPAP with improved work of breathing but still requiring respiratory support."

**P - Patient Summary:**
"She's a 78-year-old with systolic CHF (EF 30%), CKD stage 3, and atrial fibrillation. She presented at 2 AM with 2 days of worsening shortness of breath. She ran out of her Lasix a week ago. On arrival she was in acute respiratory distress with bilateral rales, JVD, and peripheral edema. She was placed on BiPAP and given 80mg IV Lasix. She's put out 1.8 liters of urine and her work of breathing has significantly improved."

**A - Action List:**
"Three things I need you to do:
1. Repeat her BMP at 8 AM - her potassium was 5.1 initially and creatinine 2.4. Make sure it's not worsening with diuresis.
2. Cardiology is coming to see her this morning to decide between admission to their service vs. obs unit
3. She's still on BiPAP - try to wean her if she continues to improve; she should be able to come off in the next couple hours"

**S - Situational Awareness and Contingency Planning:**
"If she worsens on BiPAP or can't wean off, she may need intubation - I've already discussed with her and she is FULL CODE. Her daughter is here and is the healthcare proxy if needed. Contact number is in the chart. Also be aware her potassium was borderline - if it rises, hold the Lasix and treat the hyperkalemia."

**S - Synthesis by Receiver:**
"Let me repeat back: 78-year-old with CHF exacerbation on BiPAP, been diuresing well. I need to recheck her labs at 8 AM, coordinate with cardiology for disposition, and try to wean BiPAP. If she deteriorates she's full code, and I need to watch the potassium. Anything else?"

### Critical Information Included

**What Makes This Handoff Complete:**
- Illness severity clearly stated
- Pertinent history and overnight course summarized
- Active issues identified with specific tasks
- Anticipatory guidance provided ("if/then" statements)
- Code status clarified
- Family/decision-maker identified
- Opportunity for questions

### Common Handoff Failures to Avoid

| Failure | Example | Better Approach |
|---------|---------|-----------------|
| Missing acuity | "She's a CHF patient in 12" | "She's SICK - on BiPAP" |
| No action items | "Cardiology will see her" | "Cardiology needs to decide admit vs obs, call them at 8 if they haven't come" |
| No contingency | "She's doing okay" | "If she can't wean BiPAP, may need intubation" |
| Buried code status | Not mentioned | "Full code, daughter is proxy" |
| No read-back | "Any questions?" (and move on) | Actually wait for synthesis |

### Subsequent ED Course

**8 AM Labs:**
- Potassium: 4.8 (improved)
- Creatinine: 2.6 (slightly worse but expected with diuresis)
- BNP: 1840 (down from 2400)

**9 AM:**
- Successfully weaned from BiPAP to nasal cannula 4L
- Breathing comfortably
- Cardiology saw patient

**Disposition:**
- Admitted to cardiology observation unit
- Continued diuresis
- Discharged day 2 with medication reconciliation

### Handoff Documentation

**Documentation Note:**

"7:00 AM - Handoff given to Dr. Smith (day shift):
- Patient remains on BiPAP with improved respiratory status
- 1.8L diuresis overnight
- Pending: 8 AM labs (BMP), cardiology evaluation for disposition
- Contingency planning discussed: If unable to wean BiPAP or respiratory deterioration, may require intubation; patient is FULL CODE
- Family aware and updated (daughter present)"

### Teaching Points

1. **Structured handoffs reduce errors:** IPASS, SBAR - use a framework every time
2. **State illness severity upfront:** "Sick" vs "stable" frames the conversation
3. **Action items must be specific:** Not "follow up labs" but "repeat BMP at 8 AM"
4. **Anticipatory guidance is key:** "If X happens, do Y"
5. **Code status is essential:** Always know and communicate
6. **Read-back confirms understanding:** Don't skip this step
7. **Face-to-face is preferred:** More effective than written alone
8. **Document the handoff:** Protects patients and providers

### Clinical Image
![IPASS Handoff Framework](case_02_image.jpg)

**Image Description:** Diagram illustrating the I-PASS handoff communication framework showing the five components: Illness severity, Patient summary, Action list, Situation awareness/contingency planning, and Synthesis by receiver.

**Attribution:** Image from I-PASS Study Group materials. Educational use. Source: https://www.ipasshandoffstudy.com/

---

## Case 3: Difficult Consultant Communication - Getting the Admission

### Patient Demographics
- **Age:** 45 years
- **Sex:** Female
- **Occupation:** Small business owner

### Clinical Scenario

**Situation:** It's 11 PM. You have a patient with diabetic ketoacidosis requiring admission. The medicine resident you're calling seems reluctant to accept the patient because they're overwhelmed with admissions. You need to effectively advocate for your patient.

### Patient Summary

**One-liner:** 45-year-old female with type 1 diabetes presenting with DKA (pH 7.18, glucose 480, bicarbonate 10, AG 28) triggered by UTI, now on insulin drip and fluids requiring ICU vs. step-down admission.

### Initial Call (Ineffective)

**ED Physician:** "Hey, I have a DKA for you in room 8."

**Medicine Resident:** "What's the pH?"

**ED Physician:** "7.18"

**Medicine Resident:** "That sounds pretty bad. She probably needs the ICU."

**ED Physician:** "I don't think she needs ICU, she's mentating fine."

**Medicine Resident:** "Well, she's pretty sick. I'm already overwhelmed tonight. Can you call the ICU?"

**ED Physician:** "The ICU won't take her if she doesn't need it. Can you just come evaluate her?"

**Medicine Resident:** "I really don't have time. Can she wait until morning?"

**Problems with this call:**
- No structure
- No clear communication of urgency
- No anticipatory planning
- Became adversarial
- No resolution

### Effective Consultation Call

**Using 5 C's of Consultation:**

**1. Contact:** "Hi, this is Dr. Johnson from the ED calling about an admission. Is this the medicine resident covering admissions? Great. Do you have 2 minutes?"

**2. Communicate (SBAR):**
- **S (Situation):** "I have a 45-year-old woman with DKA who needs admission tonight."
- **B (Background):** "She has type 1 diabetes, good compliance usually, but developed a UTI over the last few days and missed a few insulin doses. She presented with nausea, vomiting, and abdominal pain."
- **A (Assessment):** "She has moderate-severe DKA. Her pH is 7.18, glucose 480, bicarb 10, anion gap 28. She's currently mentating well with a GCS of 15 and hemodynamically stable on fluids."
- **R (Recommendation):** "I've started her on an insulin drip per protocol and aggressive IV fluids. She's had 2 liters so far. She needs ongoing monitoring and protocol management. I think she's appropriate for a step-down or close monitoring floor bed rather than ICU given her mental status, but I'd like you to evaluate and help determine the right level of care."

**3. Core Question:** "Can you accept this patient for admission to your service for DKA management?"

**4. Collaborate:** "What else would be helpful before you see her? I can have the labs trending, and I'll make sure she's ready for transfer when you're able to evaluate."

**5. Close the Loop:** "So to confirm - you'll see her in the next 30-60 minutes, and we'll plan for step-down admission pending your assessment. I'll call you if she worsens. What's the best number to reach you?"

### If Meeting Resistance

**Medicine Resident:** "I'm really overwhelmed tonight. Can this wait?"

**Effective Response:**
"I understand you're busy, and I appreciate that. Unfortunately, she does need admission tonight - she has an anion gap of 28 and is on an insulin drip that needs to be managed inpatient. She can't safely go home or wait until morning.

Let me help make this easier:
- She's stable and won't need much immediate intervention
- I've already started the insulin protocol
- Her first set of repeat labs is pending
- I'll have everything documented and ready for the transfer

When do you think you can evaluate her? I can help prioritize if needed."

### If Significant Disagreement

**Escalation Pathway:**
1. **Clarify the disagreement:** "Help me understand your concern about admitting her."
2. **Find common ground:** "We both want her in the right level of care. Let me share more about why I think step-down is appropriate."
3. **Offer alternatives:** "If you're concerned about acuity, would you be more comfortable with a monitored bed or ICU evaluation?"
4. **Escalate if necessary:** "I think we may need to involve our attendings to figure out the best plan for her."

**Key Principle:** Escalate to attendings if there's true disagreement about patient safety - this isn't "going over someone's head," it's patient advocacy.

### Documentation

**Consultation Note:**

"11:30 PM - Medicine consulted for admission
Spoke with Dr. Smith (medicine resident). Patient information communicated including presentation, labs (pH 7.18, AG 28), current management (insulin drip, IV fluids), and clinical stability.
Discussed appropriate level of care - agreed patient appropriate for step-down given hemodynamic stability and intact mental status.
Medicine resident will evaluate within 1 hour.
Patient will be transferred to step-down unit pending their evaluation."

### Outcome

**12:30 AM:** Medicine resident evaluated patient, agreed with step-down admission
**Admission:** Medicine step-down unit
**Hospital Course:** DKA resolved within 18 hours, transitioned to subcutaneous insulin, discharged day 2

### Teaching Points

1. **Structure your call:** 5 C's or SBAR - don't just "dump" information
2. **Lead with the ask:** Make it clear you need an admission (not a question)
3. **Provide relevant information:** Not the whole story, just what's pertinent
4. **Collaborate, don't combative:** You're on the same team
5. **Offer to help:** "What can I do to make this easier?"
6. **Document everything:** Including discussions about disposition
7. **Escalate when needed:** Patient safety comes first
8. **Understand their constraints:** Consultants are often overwhelmed too

### Additional Tips for Effective Consultation

**Before the Call:**
- Have all relevant information ready
- Know what you're asking for
- Review the patient yourself

**During the Call:**
- Be concise but complete
- Be professional regardless of response
- Clarify expectations

**After the Call:**
- Document the conversation
- Follow up if recommendations not followed
- Close the loop with the patient

### Clinical Image
![SBAR Communication Framework](case_03_image.jpg)

**Image Description:** Diagram showing the SBAR (Situation, Background, Assessment, Recommendation) communication framework used for structured healthcare communication and consultant calls.

**Attribution:** Image from Institute for Healthcare Improvement. Educational use. Source: http://www.ihi.org/resources/Pages/Tools/SBARToolkit.aspx