The American journal of emergency medicine
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It is not exactly known how ED physicians perform in evaluating cardiac systolic murmurs. In 203 consecutive medical ED patients with systolic murmur, we compared the initial clinical evaluation, including auscultation, with transthoracic echocardiography. Of the 203 patients, 132 (65%) had innocent murmurs and 71 patients (35%) had valvular heart disease. ⋯ Independent significant positive predictors of valvular heart disease were grade >2/6 systolic murmur (odds ratio [OR], 8.3; confidence interval [CI], 3.5-19.7, P<.001) and pathologic electrocardiogram (ECG) (OR, 8.4; CI, 3.2-22, P<.001. Patients younger than 50 years with a systolic murmur graded < or =2/6 had innocent murmurs in 98%. The initial clinical evaluation, including auscultation, by experienced ED physicians in internal medicine distinguishes well between innocent murmurs and valvular heart disease in medical patients with cardiac systolic murmurs.
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Clinicians may not perform a medical-legal examination in cases in which a sexual assault was attempted but no penile-vaginal contact occurred. This retrospective study was conducted to document the frequency and type of genital injuries in women in whom forced digital penetration was the only reported type of assault. Study patients were consecutive female patients presenting to an urban sexual assault clinic during a 3-year study period. ⋯ Fifty-six percent of the injuries occurred at four sites: fossa navicularis, labia minora, cervix, and posterior fourchette. The most common type of injury was erythema (34%) followed by superficial tears (29%) and abrasions (21%). Colposcopy with nuclear staining was useful in detecting these injuries--and can provide valuable legal information in sexual assault victims reporting only digital-vaginal penetration.
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It has been proposed that the workup of suspected subarachnoid hemorrhage should begin with lumbar puncture (LP) rather than computed tomography (CT) scan. We investigated whether EPs would in fact advocate this strategy in an index hypothetical case and in variations of the index case. An eight-question survey was distributed to EM physicians attending national continuing medical education meetings. ⋯ The "LP first" strategy for workup of subarachnoid hemorrhage was rejected by most EM physicians except when the CT scan would entail delay. Compared with the index case, an added number of physicians would advocate this strategy if the patient was uninsured. The ethical implication of advocating a strategy because of financial concerns and that most physicians would not favor for themselves or their patients merits attention.
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Evaluation of the electrocardiogram (ECG) is a complex, subjective process with the potential for interobserver disagreement. The objective of this study was to determine the ECG patterns with discrepant interpretations, the rates of disagreement in the determination of both the presence of ST segment elevation (STE) and morphology. ECGs were reviewed in a retrospective fashion by attending EPs for STE and waveform morphology. ⋯ Fourteen ECGs (8.2% of 171 ECGs with STE determined by at least 2 EPs) had ST segment morphology interpreted in a discrepant fashion. Disagreement in the determination of electrocardiographic ST segment elevation by EPs occurs frequently and is related to the amount of STE present on the ECG. Electrocardiographic patterns responsible for this interpretive disagreement of ST segment elevation can represent an unfortunate but potentially predictable source of error in emergency medical care.
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Pain is an important but understudied and often overlooked aspect of emergency medical care. This study examined the management of pain after discharged of patients from the emergency department (ED). We hypothesized that pain management after discharge would be adequate, and that patients would use their medications as prescribed. ⋯ The patients in the study were quite satisfied with their pain control. Most filled their prescriptions and did so in a timely manner. Those who did not fill prescriptions for medications reported the least satisfaction with pain control.