J Emerg Med
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Psychiatric presentations are common in emergency departments (EDs), but the standard of care for treatment remains poorly defined. We introduced standards for emergency psychiatric evaluations that included obtaining collateral information, writing a safety plan for discharging patients, identifying the next best provider, and alerting that provider to the patient's visit. ⋯ This standard work for emergency psychiatric evaluations was feasible even in a highly acute patient population. However, the benefits of this intervention are less clear. We question the utility of prevailing metrics in emergency psychiatry.
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Case Reports
Prepubertal Genital Bleeding: Examination and Differential Diagnosis in Pediatric Female Patients.
Prepubertal genital bleeding can be caused by a variety of etiologies including trauma, infection, structural, hematologic disorders, precocious puberty, and malignancy. Urethral prolapse can be seen in prepubescent girls due to a relative estrogen deficiency. Urethral prolapse classically presents with urethral mass and vaginal bleeding, often associated with constipation. ⋯ A healthy 6-year-old White girl presented to the Pediatric Emergency Department (ED) with vaginal bleeding for 1 day preceded by a few months of constipation. In the ED the patient's physical examination was remarkable for a tender, nonmobile mass at the vaginal introitus. Transabdominal pelvic and renal ultrasounds were unremarkable. The emergency physician's working diagnosis was a vaginal mass concerning for sarcoma botryoides. Pediatric and Adolescent Gynecology (PAG) was consulted. They performed an examination under anesthesia (EUA) with cystoscopy and vaginoscopy. The EUA confirmed a urethral prolapse approximately 2 cm in diameter. The patient was treated with conjugated estrogen vaginal cream. At her 1-month follow-up, the urethral prolapse had resolved. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Performing a proper pelvic examination of a prepubescent girl presenting with vulvovaginal bleeding is crucial to form an accurate diagnosis in the ED setting. By placing the young girl in the frog-leg or knee-chest position and using both lateral and downward traction of the vulva, one can adequately visualize the external genitalia and outer 1/3 of the vagina. This can help streamline diagnosis and avoid unnecessary examinations and anxiety.
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Case Reports
Novel Uses of Point-of-Care Ultrasound for Pediatric Foreign Bodies: An Emergency Department Case Series.
Foreign bodies (FBs) are a diagnostic challenge to pediatric emergency providers. Point-of-care ultrasound (POCUS) is an important adjunct to the diagnostic pathway of children with suspected FBs. ⋯ This case series describes three examples of novel extended ultrasonography uses in the pediatric emergency department for the detection of FBs involving different organ systems (i.e., abdominal, esophageal, and scrotal). WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: FBs are a diagnostic challenge to pediatric emergency providers. POCUS should be recognized as an important adjunct to the diagnostic pathway of children with suspected FBs. When used thoughtfully, it can narrow the differential diagnosis, guide further confirmatory investigations, reduce cognitive burden, and tailor downstream patient care.