From Telemedicine to the ICU—Fever and Rash in a 9-Year-Old Girl

PEDIATRICS ◽  
2021 ◽  
Author(s):  
Salvador Maffei ◽  
Marietta De Guzman ◽  
Ryan Rochat ◽  
Jennifer Tran ◽  
Sarah Risen ◽  
...  
Keyword(s):  
Primary Care ◽  
Emergency Department ◽  
Laboratory Testing ◽  
Inflammatory Markers ◽  
Cervical Lymphadenopathy ◽  
Definitive Diagnosis ◽  
Upper Extremities ◽  
Laboratory Results ◽  
Intravenous Hydration ◽  
Primary Care Pediatrician

A 9-year-old girl presented to her primary care pediatrician via telemedicine during the initial months of the coronavirus disease 2019 pandemic because of 4 days of warmth perceived by her mother, decreased energy, and a new rash on her upper extremities. After 10 additional days of documented fever >38°C, worsening fatigue, and 1 day of nausea, vomiting, and diarrhea, she was allowed to schedule an in-person visit with her pediatrician after testing negative for severe acute respiratory syndrome coronavirus 2. She appeared ill on arrival to clinic, and her pediatrician recommended evaluation in an emergency department. Her initial laboratory testing revealed nonspecific elevation in several inflammatory markers and leukopenia, and she responded well to intravenous hydration. Over the next 2 weeks, her fever persisted, constitutional symptoms worsened, and she developed progressively painful cervical lymphadenopathy and pancytopenia. She was evaluated in clinic by several specialists and eventually was urged to present to the emergency department again, at which time she was admitted to the PICU. After consulting additional specialists and waiting for laboratory results, the team reached a definitive diagnosis and initiated therapy; however, she experienced rapid clinical decline shortly thereafter. The specialists who assisted with identification of the underlying etiology of her symptoms were able to work together to manage the subsequent complications.

Sudden Sensorineural Hearing Loss in the Department of Defense

2018 ◽  
Vol 159 (2) ◽  
pp. 354-358 ◽  
Author(s):  
Charlotte K. Hughes ◽  
Jakob Fischer ◽  
Carlos R. Esquivel ◽  
Adrienne M. Laury
Keyword(s):  
Primary Care ◽  
Emergency Department ◽  
Hearing Loss ◽  
Sensorineural Hearing Loss ◽  
Medical Record ◽  
Department Of Defense ◽  
Laboratory Testing ◽  
Sudden Sensorineural Hearing Loss ◽  
Intratympanic Steroids ◽  
Nose And Throat

Objective The American Academy of Otolaryngology—Head and Neck Surgery Foundation clinical practice guideline (CPG) proposes recommendations regarding sudden sensorineural hearing loss (SSNHL). SSNHL is managed by primary care, emergency medicine, and otolaryngology providers in the Department of Defense (DoD). However, their adherence to this CPG is unknown. We sought to determine provider compliance and identify areas for improvement. Study Design Case series with chart review. Setting DoD’s electronic medical record. Subjects and Methods Patients with SSNHL (N = 204) were treated between March 1, 2012, and September 30, 2015. Time from onset of symptoms to evaluation by primary care, emergency department, audiology, and otolaryngology providers and treatments were analyzed. Results The average interval from onset of symptoms to evaluation by a primary care or emergency department provider was 4.86 days (95% CI, 3.46-6.26). Time from presentation to ear, nose, and throat and audiologic evaluation was 15.26 days (95% CI, 12.34-18.20) and 14.16 days (95% CI, 11.31-17.01), respectively. Diagnostic workup included magnetic resonance imaging (n = 150, 73.5%), computed tomography (n = 28, 13.7%), and laboratory testing (n = 50, 24.5%). Oral steroids were used in 137 (67.2%) patients, with 78.8% treated with the recommended dose. Intratympanic steroids were utilized in 65 (31.9%) patients, with variable dosing. Conclusion The DoD is uniquely positioned to evaluate adherence to CPGs on national and international levels given the robust and standardized electronic medical record. Areas of improvement include timely identification of SSNHL with rapid referral to ear, nose, and throat and audiology providers; minimizing unnecessary imaging, laboratory testing, and medications; and correct dosing of oral and intratympanic steroids.

Hypercalcemia in the Emergency Department: A Missed Opportunity

2014 ◽  
Vol 80 (8) ◽  
pp. 732-735 ◽  
Author(s):  
Anna Marie Royer ◽  
Reid A. Maclellan ◽  
J. Daniel Stanley ◽  
Trent B. Willingham ◽  
W. Heath Giles
Keyword(s):  
Primary Care ◽  
Emergency Department ◽  
Care Physician ◽  
Definitive Diagnosis ◽  
Chief Complaint ◽  
Delay In Diagnosis ◽  
Discharge Disposition ◽  
Discharge Plan ◽  
Acute Condition ◽  
Missed Opportunity

Primary hyperparathyroidism is surgically correctable and frequently presents with mild hypercalcemia. The symptoms of hyperparathyroidism are nonspecific often leading to a delay in diagnosis until patients present with an acute condition. Literature suggests that up to 20 per cent of patients presenting to the emergency department (ED) found to have hypercalcemia are ultimately diagnosed with hyperparathyroidism. We performed a retrospective review from 2012 to 2013 of patients with hypercalcemia in our ED and analyzed their characteristics. One hundred sixty-eight patients were identified with hypercalcemia. Patient medical history, chief complaint, review of symptoms, discharge disposition, and primary care physician (PCP) status were evaluated. Eighty-four per cent were classified as mild (10.8 to 11.9 mg/dL), 11 per cent as moderate (12 to 14 mg/dL), and five per cent as severe (greater than 14 mg/dL). A definitive diagnosis of hyperparathyroidism was identified in 3.5 per cent (six of 168). Documentation of hypercalcemia as a diagnosis was present in all patients in the severe and 78 per cent in the moderate categories. However, only 21 per cent of patients with mild hypercalcemia had documentation addressing this diagnosis. Of concern, 24 per cent (41 of 168) of patients were identified with mild hypercalcemia and discharged from the ED with no definitive plan based on lack of a PCP. Additionally, 81 per cent of these patients had symptoms referable to hypercalcemia. Mild hypercalcemia found during ED workup rarely requires immediate medical treatment. However, a significant number of those patients will have hyperparathyroidism amendable to surgical correction. Therefore, an appropriate mechanism for outpatient hypercalcemia workup should be integrated into the patient's ED discharge plan.

scholarly journals The diagnostic process of covıd-19 in the emergency department: laboratory and ımaging methods

2020 ◽  
Vol 66 (suppl 2) ◽  
pp. 58-64
Author(s):  
Fatih Guneysu ◽  
Yusuf Yurumez ◽  
Ertugrul Guclu ◽  
Mehmet Koroglu ◽  
Alper Karacan ◽  
...  
Keyword(s):  
Emergency Department ◽  
Inflammatory Markers ◽  
Reference Range ◽  
Early Stage ◽  
Diagnostic Process ◽  
Rt Pcr ◽  
Significant Difference ◽  
Laboratory Results ◽  
Novel Coronavirus

SUMMARY OBJECTIVES The 2019 Novel coronavirus disease puts a serious burden on the health system. Therefore, the detection of particularly serious patients at an early stage is extremely important in terms of controlling the outbreak and improving the prognosis. We investigated the role of inflammatory markers studied in patients suspected of COVID-19 at an emergency department in predicting PCR and CT results. METHODS This retrospective study was carried out with 133 patients who were admitted between 13 March and 1st April 2020 with suspicion of COVID-19. The patients were divided into four groups according to CT and RT-PCR results and evaluated. RESULTS Considering all patients, no specific findings were found in the hematological and biochemical values of patients in the laboratory analyses. Although all of the results remained within the reference range, there was a significant difference in white blood cell, neutrophil, platelet, and lymphocyte values when the groups were compared [p = 0.000; p = 0.004; p = 0.022; p = 0.023]. CONCLUSION Laboratory is not specific enough in the pre-diagnosis. In addition, this result does not alter with PCR or CT positivity. However, minimal changes observed in laboratory results may be partially guiding in patients in whom both PCR and CT are positive.

scholarly journals 140. Symptoms and Situations Predispose Patients to Use Antibiotics Without Medical Advice

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S200-S200
Author(s):  
Michael Hansen ◽  
Barbara Trautner ◽  
Roger Zoorob ◽  
George Germanos ◽  
Osvaldo Alquicira ◽  
...  
Keyword(s):  
Primary Care ◽  
Emergency Department ◽  
Emergency Departments ◽  
Primary Care Clinic ◽  
Antibiotic Use ◽  
Safety Net ◽  
Care Clinic ◽  
Primary Care Clinics ◽  
Primary Care Patients ◽  
Emergency Department Patients

Abstract Background Use of antibiotics without a prescription (non-prescription use) contributes to antimicrobial resistance. Non-prescription use includes obtaining and taking antibiotics without a prescription, taking another person’s antibiotics, or taking one’s own stored antibiotics. We conducted a quantitative survey focusing on the factors that impact patients’ decisions to use non-prescription antibiotics. Methods We surveyed patients visiting public safety net primary care clinics and private emergency departments in a racially/ethnically diverse urban area. Surveys were read aloud to patients in Spanish and English. Survey domains included patients’ perspectives on which syndromes require antibiotic treatment, their perceptions of health care, and their access to antibiotics without a prescription. Results We interviewed 190 patients, 122 from emergency departments (64%), and 68 from primary care clinics (36%). Overall, 44% reported non-prescription antibiotic use within the past 12 months. Non-prescription use was higher among primary care clinic patients (63%) than the emergency department patients (39%, p = 0.002). The majority felt that antibiotics would be needed for bronchitis (78%) while few felt antibiotics would be needed for diarrhea (30%) (Figure 1). The most common situation identified “in which respondents would consider taking antibiotics without contacting a healthcare provider was “got better by taking this antibiotic before” (Figure 2). Primary care patients were more likely to obtain antibiotics without prescription from another country than emergency department patients (27% vs. 13%, P=0.03). Also, primary care patients were more likely to report obstacles to seeking a doctor’s care, such as the inability to take time off from work or transportation difficulties, but these comparisons were not statistically significant. Figure 1. Patients’ agreement that antibiotics would be needed varied by symptom/syndrome. Figure 2. Situations that lead to non-prescription antibiotic use impacted the two clinical populations differently Conclusion Non-prescription antibiotic use is a widespread problem in the two very different healthcare systems we included in this study, although factors underlying this practice differ by patient population. Better understanding of the factors driving non-prescription antibiotic use is essential to designing patient-focused interventions to decrease this unsafe practice. Disclosures All Authors: No reported disclosures

Presentation and Referral Patterns in Pediatric Closed Hand Fractures

Hand ◽  
2021 ◽  
pp. 155894472110085
Author(s):  
Landis R. Walsh ◽  
Laura C. Nuzzi ◽  
Amir H. Taghinia ◽  
Brian I. Labow
Keyword(s):  
Primary Care ◽  
Emergency Department ◽  
Pediatric Patients ◽  
Primary Care Providers ◽  
Care Providers ◽  
Referral Patterns ◽  
Old Patients ◽  
Hand Surgeon ◽  
Hand Fractures ◽  
The Mean

Background Although pediatric hand fractures are common and generally have good outcomes, they remain a considerable source of anxiety for non–hand surgeons, who are less familiar with these injuries. We hypothesized that this anxiety may manifest as inefficiency in referral patterns. Methods The records of pediatric patients with isolated, closed hand fractures without concurrent trauma seen at our institution by a hand surgeon between January 2017 and December 2018 were retrospectively reviewed. Results There were 454 patients included; 62.1% were men, and the mean age was 9.6 years at initial encounter. Most patients (89.6%) were treated nonoperatively and incurred few complications (0.5%). Roughly half of all cases (n = 262) initially presented to an outside provider. Of these, 24.0% (n = 64 of 262) were evaluated by 2+ providers before a hand surgeon. Most commonly, these patients were referred from an outside emergency department (ED) to our ED before hand surgeon evaluation (n = 45 of 64). Forty-seven patients required surgery; however, none were performed urgently. Although a greater proportion of 7- to 11-year-old patients saw 2+ providers prior to a hand surgeon ( P = .007), fewer required surgery ( P < .001). Conclusions Pediatric closed hand fractures are mainly treated nonoperatively and nonemergently with generally excellent outcomes. Our data suggest that many patients continue to be referred through the ED or multiple EDs/providers for treatment. These inefficient referral patterns demonstrate the need for better education for ED and primary care providers, as well as better communication between these providers and local pediatric hand surgeons. Advancements in these areas are likely to improve efficiency of care and decrease costs.

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