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Go away, not for you

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General

EWS

GCS 15/15, alert, conversational. Examination reassuring, chest clear, HS 1+2+0. Abdomen soft non-tender, tolerating deep palpation all quadrants. No masses felt. Bowel sounds normal. Calves SNT. CRT<2s, warm and well perfused to peripheries.

Bloods demonstrating

Chest Pain

No personal or family cardiac history inclusive of IHD identified.

EWS

GCS 15/15, alert, conversational. Examination reassuring, chest clear to bases, no WOB. HS 1+2+0. Abdomen soft non-tender, no masses felt. Calves SNT. CRT<2s, warm and well perfused to peripheries.

Chest not tender to palpation. Tolerating deep breaths without issue. No evidence of pedal or sacral oedema

Bloods demonstrating

Trop

ECG sinus, HR

CXR

EDACS score, PERC score, Wells score,

Chest pain, unclear cause, acute cardiac or respiratory pathology unlikely. Discharged with analgesia and strict safety netting.

Discussed with ED SMO happy with the above.

Paediatric

PEWS

Appearance for a relatively well looking child.

Alert, playing, interacting well with carers and myself. Understandably grumpy when examined.

Chest clear to auscultation, HS 1+2+0, abdomen SNT, bowel sounds normal. Good peripheral and central pulses, CRT<2s, warm and well perfused to peripheries. No evidence of increased WOB or accessory muscle use. No tenderness or obvious injury to the head, scalp, or neck including mastoids. TM clear bilaterally, throat examination clear. No obvious cervical lymphadenopathy.

Anterior fontanelle present, normal palpation, flat. No evidence of rash/skin lesion to full exposure of the head/limbs/torso/groin. Normal eye movements to distraction testing, moving head/neck freely.

Treated with simple PO analgesia/antipyretics to good effect.

Tolerating PO intake in department.

No evidence of acute pathology identified, neither respiratory distress or evidence of significant dehydration. Live locally, access to car and phone confirmed. Strict safety netting given, and as standard, recommendation of GP follow-up in 3-5 days to ensure resolution of symptoms.

Discussed with ED SMO happy with the above

Neurological

PEARL

Normal coordinated eye movements and visual fields, no nystagmus. Normal facial movements and sensation, including full RoM of the neck. No scalp/mastoid tenderness or injury, no midline tenderness to the cervical and full spine.

Grossly normal neurology to the UL and LL, including normal gait, normal power including power/precision grip, normal sensation, normal tone. Brisk reflexes

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