Biomedical subjects
Publications and source records attributed to F L Counselman.
A case of hypersensitivity pneumonitis in a 40-year-old patient secondary to a pet bird is presented. The clinical presentation, diagnosis, and management of hypersensitivity pneumonitis are reviewed.
Thirty-six patients with a history of asthma who presented to an emergency department (ED) with an acute exacerbation were studied prospectively to determine if a correlation existed between peak expiratory flow rate (PEFR) and speaking time. Each patient listened to an instructional audiotape on the proper method of counting and then maximally inhaled and counted until it became necessary to take a second breath. This represented the patient's "speaking time" in seconds. A PEFR was then obtained using a hand-held peak flow meter. The speaking time and PEFR were measured before and after each nebulized albuterol treatment. A total of 169 pairs of pretreatment and posttreatment PEFR and speaking time measurements were obtained. Regression analysis of the PEFR and speaking time demonstrated the PEFR can be predicted by the speaking time with statistical significance (P < .0001). The regression analysis equation was: peak flow (L/min) = 114.8 +/- (17.6 x speaking time).
OBJECTIVE: To survey academic departments of emergency medicine (ADEMs) concerning the effects of managed care on their operation and practice. METHODS: A 38-question survey was mailed to the chairs of all 52 ADEMs in the United States requesting information concerning managed care activity and its effects on ADEMs in academic years 1994-1995 and 1995-1996. RESULTS: Forty-seven ADEMs (90.3%) responded. When comparing the 1995-1996 and 1994-1995 academic years, the following changes were noted: decreased overall growth in ED patient volume (38.3% vs 51.1%), larger percentage of respondents reporting an actual decrease in ED patient volume (38% vs 27.6%), less growth in ED gross revenue (43.7% vs 52.1%), larger percentage of ADEMs reporting actual decreased gross revenues (25% vs 12.5%), increase in ED patient acuity (76.6% vs 59.6%), and relative stability in the number of EM faculty (40.4% vs 44.7% reporting no change in faculty number). Two-thirds of ADEMs used mid-level providers (i.e., physician assistants, nurse practitioners), most commonly in a fast-track setting (41%). Thirty percent of ADEMs reported that other academic departments actively directed patients away from the ED, with pediatrics, family medicine, and internal medicine the most active. Ninety-eight percent of ADEMs reported ongoing negotiations between their institution or hospital and managed care organizations (MCOs); only 54.3% of ADEMs were involved in these negotiations. Twenty-eight percent of ADEMs reported MCOs have had an effect on their emergency medical services system, with 37% indicating HMOs routinely discouraged their enrollees from using 9-1-1 services and 16% reporting HMOs provided 9-1-1 services to take patients only to participating hospital EDs. CONCLUSION: ADEMs have experienced significant changes in nearly every aspect of their practice over the two academic years under study, much of which is due to managed care. ADEMs must take a leadership role in dealing with MCOs.
The incidence of creatine phosphokinase (CPK) elevation was evaluated in patients presenting to an urban emergency department with any complaint related to cocaine use within the preceeding 24 hours. Patients with obvious causes of CPK elevation (ie, seizure) were excluded. Forty patients were enrolled. CPK values were elevated in 21 patients (53%). The mean CPK value for patients with an elevated CPK was 1,071 IU/L. There was no statistically significant difference between the patient's initial complaint (muculoskeletal, psychiatric, or cardiovascular) and the incidence of CPK elevation (P = .35). Thirty of the 40 patients admitted to using some other drug(s) in addition to cocaine in the preceding 24 hours. Some degree of skeletal muscle injury and CPK elevation appears to be common in patients using cocaine.
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A complete understanding of the anatomy, pathophysiology, and presenting signs and symptoms of appendicitis, combined with a thorough history and physical examination, will be the most important factors in allowing the practicing emergency physician to make the correct diagnosis of acute appendicitis. For patients in which the diagnosis is less clear or for patients in high-risk groups (extremes of age, pregnant women, and immunocompromised patients) additional diagnostic testing, usually US or CT, and early surgical consultation are recommended.
This two-part study was designed to determine the reading level necessary to understand commonly used emergency department (ED) discharge instructions and the functioning reading level of adult patients treated in an urban hospital ED. In the first phase, 10 preprinted patient discharge instructions were analyzed using the Flesch Reading Ease Score. The average reading level required to comprehend these instructions was 9.8, with a range from the 8th to the 14th grade. In the second phase of the study, a reading exam, based on the Stanford Diagnostic Reading Test, was administered to 82 ED patients prospectively. The mean reading level was 9.8, with a median level of 10; approximately 45% of the ED patients would be unable to understand the preprinted discharge instructions. ED discharge instructions are frequently written at a level beyond the comprehension of a significant portion of the population.
A case of infectious mononucleosis (IM) in a two-year-old patient is presented. The clinical presentation and diagnosis of IM in young children are discussed.
The usefulness of subcutaneous injection of three local anesthetic agents to stimulate tick detachment in an animal model was evaluated. American dog ticks (Dermacentor variabilis) were placed on three New Zealand white rabbits and allowed to attach for 24 hours. Dead and unattached ticks were manually removed. Three local anesthetic agents were studied: 1% lidocaine (group A); 1% lidocaine with epinephrine 1:200,000 (group B); and 1% chloroprocaine (group C). For each group, a total of 0.25 mL of anesthetic agent was injected subcutaneously under the attached portion of each tick, resulting in formation of a 5- to 6-mm wheal. For all three anesthetic agents studied (group A, 34 ticks; group B, 28 ticks; group C, 31 ticks), none of the ticks spontaneously detached within 1 hour after injection. Subcutaneous injection of 1% lidocaine, 1% lidocaine with epinephrine, and 1% chloroprocaine are not effective methods for rapid tick removal in the animal model.
STUDY OBJECTIVE: To compare transcribed and handwritten emergency department charts for completeness of documentation. DESIGN: Convenience sample, retrospective chart review. SETTING: Level I tertiary-care referral center and primary training site for a fully accredited postgraduate year 2 through postgraduate year 4 emergency medicine residency program. PARTICIPANTS: Two hundred two patients admitted to telemetry or CCU/ICU with a final diagnosis of myocardial infarction, unstable angina, rule out myocardial infarction, or evaluation of chest pain from July 15, 1990, through June 30, 1991. INTERVENTIONS: Each chart, unknown to the faculty and residents, was reviewed for documentation of the presence or absence of 28 critical items. Equal weight was given to each item. Two-tailed testing for independent proportions was used to determine the presence of a statistically significant difference between the transcribed and handwritten charts. In addition, the mean and SD for the number of critical items documented were determined for both the transcribed and handwritten charts. A two-tailed Student t test was used to determine the presence of a statistically significant difference. Significance was set at a P value of less than .05. RESULTS: Ninety-four transcribed and 108 handwritten charts were reviewed. Transcribed charts contained a greater proportion of the 28 critical items than did the handwritten charts (P < .05). The mean number (19.6 +/- 4.0) of critical items present in the dictated charts was significantly greater than the mean number (15.8 +/- 4.0) of items present in the handwritten charts (P < .0001). CONCLUSION: Transcribed ED charts contain more complete documentation than handwritten charts in the evaluation of patients who present with chest pain of suspected ischemic origin.
The use of serum amylase levels in the diagnosis of acute pelvic inflammatory disease (PID) was investigated prospectively. Eighty-five women presenting with the chief complaint of lower abdominal pain were entered into the study; all patients were examined by one of the principal investigators. In addition to the usual laboratory studies, a serum amylase level was obtained on all patients; the investigators were blinded to the results. Patients were diagnosed with PID if they fulfilled previously published clinical criteria. Forty-eight patients met the criteria for the diagnosis of PID (PID group); 37 patients were diagnosed with other disease processes (non-PID group). The average serum amylase level for the PID group was 62 U/L, with a standard deviation (STD) of 24; for the non-PID group, the average was 76 U/L with an STD of 32. Although there was a statistical difference between the two groups (P < .05), there was no clinically significant difference because both values fell within the normal range of serum amylase. The routine use of serum amylase in the diagnosis of acute PID seems to be of no value.
Pheochromocytoma is classically associated with paroxysms of headache and hypertension. Its presentation, however, may be more varied and subtle. We present a case of an adolescent female who complained of right upper quadrant and flank pain. A right adrenal pheochromocytoma was diagnosed and subsequently removed. The pertinent literature is discussed.
A case of Fitz-Hugh-Curtis syndrome masquerading as a perforated peptic ulcer is presented. The pathophysiology, clinical presentation, differential diagnosis, and management of this syndrome are discussed.
A case of altered mental status secondary to pneumocephalus as a complication of sinus surgery is presented. The pathophysiology, clinical presentation, diagnosis, and management of pneumocephalus are discussed.
A case of spontaneous pneumomediastinum secondary to hyperemesis gravidarum is presented. The pathophysiology, clinical presentation, differential diagnosis, and management of this unusual complication of hyperemesis gravidarum are reviewed.
The purpose of this study was to determine if pelvic ultrasound was useful in suggesting the diagnosis of ectopic pregnancy in patients with a quantitative B-hCG level less than 1000 mIU/mL. We performed a retrospective review of all patients evaluated and diagnosed with ectopic pregnancy in the emergency departments of seven area hospitals during a ten month period. Sixty-four patients with a confirmed diagnosis of ectopic pregnancy, a pelvic ultrasound, and a quantitative B-hCG level were included in the study. Eighteen (28%) of these patients had a quantitative B-hCG less than 1000 mIU/mL. Sixteen of the eighteen patients (89%) with a B-hCG level less than 1000 mIU/mL had sonographic findings suggestive of ectopic pregnancy, such as fluid in the cul-de-sac, or a complex adnexal or cystic mass. Overall, 25% of all patients diagnosed with an ectopic pregnancy during this time period had a quantitative B-hCG level less than 1000 mIU/mL and an ultrasound suggestive for ectopic pregnancy. Pelvic ultrasound is useful as a screening tool in the initial evaluation of suspected ectopic pregnancy, even when the quantitative B-hCG level is below 1000 mIU/mL.
Marine-related injuries and envenomations are common to the coastal physician. Needlefish injuries, which occur almost exclusively in the Indo-Pacific region, have not previously been reported along the Atlantic seaboard. This case report describes a penetrating injury to the lower extremity from a needlefish. Treatment is guided by general resuscitative procedures as well as antibiotic therapy directed against infections unique to the marine environment.