Second Case August 4, 2013 Case Management Commentary

Click this link to download the case file from box.net:https://app.box.com/s/67pzhchfot69w684d9k7
If you do not download the file after opening the link in box.net, then you will not be able to easily see all of the information in the file.

The second case involves an 81 year-old male patient s/p fall with forehead abrasion and contusion. There are no neurologic deficits. A CT scan in the ER (no formal reading found in chart) is stated in ER records to have areas suspicious for tiny hemorrhagic contusions. A bleeding time is performed 6.5 hours post-admission and is elevated (11.0 minutes; N: 4-9 minutes). If data is missing, you can assume that information was not documented in the chart or is reported to be unremarkable or negative.

The patient was hospitalized 7.1 days and was transfused six platelet pheresis units at 8:12, 8:23, 13:35, 15:00, 22:51 and 24:18 hours post-admission. The transfusion start and stop times were not recorded in 3 of 6 transfusions and consequently the start time is listed for only 3 units.

Objective Data:

Row 19: ER assessment with head trauma from fall. CT in ED but no formal radiology report found; ED notes state small amount of gyral high densities suspicious for a tiny hemorrhagic contusions in frontal lobes (m44, m49, m 51, m53 and m54). There is no mention of home medication.

Row 25: Platelet count 230,000.

Row 30: Bleeding time 11.0 minutes (N: 4-9 minutes)

Row 34, 35: Two units platelet pheresis released by blood bank 8 hours 12 minutes post-admission.

Row 36: One platelet pheresis transfused; no start time recorded for second platelet pheresis unit.

Row 41: Post-transfusion bleeding time 13.00 minutes, performed 3 hours 07 minutes post recorded platelet transfusion start time. No transfusion stop times were recorded for either platelet transfusion.

Row 45, 50: Back-to-back platelet pheresis transfusions given 13:35 and 15:00 hours post-admission.

Row 53: Platelet count 340,000 performed 18:25 hours post-admission.

Row 54: Bleeding time 13.00 minutes performed 18:35 hours post-admission.

Row 55: CT Head Small areas of blood, in two areas (L posterior frontal cortex and R posterior frontal sulcus); other previous findings not seen today. Report does not specifically list “previous” study date, time or specific findings. Report for prior study not found in chart.

Row 57: Platelet count 337,000 performed 19 hours 57 minutes post-admission

Row 63, 70: Two units platelet pheresis released by blood bank 22:51 and 24:18 hours post-admission. No transfusion start and stop times recorded.

Row 73: Bleeding time 8.00 minutes performed 25: 25 hours post admission.

Row 80: H&H performed 32 hours 55 minutes post-admission and 19 hours 29 minutes post-release of last platelet pheresis unit.

Row 84, 89, 94, 97, 99, 101: Subsequent platelet counts 297, 241, 214, 210, 189 and 176 between 45:15 hours and 164:15 hours post-admission. Hospital length of stay: 7.1 days.

Assessment and Conclusion: see additional discussion