Common Medical Presentations Research Articles

Clinical Presentations, Physician Consultations and Patient Transport Options for Australian Remote and Industrial Paramedics

Introduction The aim of this study was to provide a snapshot of Australian remote and industrial paramedics’ patient clinical presentations, experience with physician consultations and options for patient transport to tertiary care. Methods This exploratory, cross-sectional descriptive study employed a purpose-built online survey. Participants were 78 paramedics working in Australian rural and remote industrial settings recruited in 2015 using web-based, respondent-driven sampling. In addition to a series of closed ended questions, respondents were asked to recall the number of times they encountered specific clinical presentations during the past year. Data were analysed using descriptive statistics and modes were calculated for ordinal data associated with clinical presentations. Results The traumatic presentations that participants recalled encountering at least 10 times the preceding year included back pain (39.7%), minor lacerations (38.5%), joint (36.4%) and hand (30.8%) injuries. Respondents selected headache (64.1%), nausea, vomiting or diarrhoea (52.6%), respiratory infections (50%), ear, nose or throat problems (43.6%) and localised infections or rash (39.7%) as the most common medical presentations. Of the respondents, 38.4% managed patients with mental health presentations a minimum of six times in the preceding year, and 45.3% treated at least one patient in cardiac arrest. While 94.8% of participants said topside support was available, over half described consulting physicians infrequently and if they did, it was typically by telephone. Most respondents (61%) indicated that their worksite was located over 100 km from a hospital. Conclusion Survey findings indicate that paramedic participants recall encountering a wide range of clinical presentations and managing low acuity illnesses more commonly than traumatic injuries. Most respondents were located at least 100 km from the nearest hospital and although almost all had access to topside support, over half stated they consulted physicians infrequently.

Current best practices in emergency evaluation and management of syncope.

Syncope is a common medical presentation that can cost the US healthcare system up to $2.4 billion dollars annually. Much of this cost can be mitigated with proper evaluation and management in the urgent care setting, as well as appropriate use of a risk stratification system.

The clinical anatomy of variations of the pectoralis minor.

Shoulder pathology is a very common medical presentation and can be due to anatomical variations. Therefore, knowledge of variants is important for the clinician treating patients with such complaints so that misdiagnosis is minimized and iatrogenic injury prevented. A review of the literature was performed of the variant anatomy of the pectoralis minor muscle. The aim of this review is to better inform clinicians who might treat patients with shoulder pathology so that if identified, variants of the pectoralis minor muscle are better appreciated.

Evaluation of the prognostic value of the neutrophil to lymphocyte ratio, lactate dehydrogenase enzyme, and proteinuria in patients with acute pancreatitis admitted at Assiut University Hospitals and its correlation with Ranson\u2019s criteria scoring system

BackgroundAcute pancreatitis is a relatively common acute medical presentation that may progress beyond the pancreas to cause multi-organ failure or death. It is associated with high morbidity and mortality with mortality rates changing little in the past few decades despite advances in intensive care and surgical management. Early evaluation of acute pancreatitis severity is essential to allow the clinician to predict the patient’s clinical course, estimate the prognosis, determine the need for intensive care unit admission, and prevent complications. So, the purpose of our study is to evaluate the prognostic value of the neutrophil to lymphocyte ratio, lactate dehydrogenase enzyme, and proteinuria in patients with acute pancreatitis and its correlation with Ranson’s criteria scoring system as new, rapid, and easy parameters to predict severity of acute pancreatitis.ResultsThe mean age of patients in years was 47.97, and the median was 52 with a range of ages between 18 and 87; 38% of the patients included were males, and 61% were females. The mean Ranson’s score was 2.77 ± 1.4, and the median was 3 with a range of 0–6; 44.5% of patients included have low severity, 42.4% have mild severity, and 13.1% of patients have high severity. Neutrophil to lymphocyte ratio both at the time of admission and after 48 h of admission was significantly increasing with an increase in disease severity with a P value of < 0.001 that was statistically significant. Lactate dehydrogenase enzyme at the time of admission was also significantly increasing with diseased severity with a P value of 0.001 that was statistically significant and the same for lactate dehydrogenase enzyme level after 48 h of admission with a P value of 0.002 that was also statistically significant. Proteinuria is positive only in 15.2% of patients and with the same result after 48 h of admission.ConclusionThe neutrophil to lymphocyte ratio gives a rapid impression of the extent of the inflammatory process, and it can effectively predict severity at the time of admission and even after 48 h of admission and can also differentiate between patients with mild and severe acute pancreatitis in both calcular and non-calcular cause-dependent acute pancreatitis patients. Lactate dehydrogenase can be used to predict severity in calcular cause-dependent acute pancreatitis patients only at the time of admission and after 48 h of admission. Proteinuria in urine analysis on admission and after 48 h does not seem to be a reliable predictor for disease severity in acute pancreatitis.

A Study of the Pattern of Admissions to the Accident and Emergency (A&E) Department of a Tertiary Care Hospital in Sri Lanka.

Introduction The latest national healthcare reform policies of Sri Lanka include the development of accident and emergency (A&E) departments in all major hospitals. Provincial General Hospital Kurunegala (PGHK) is a home to the first established A&E department in Sri Lanka. PGHK provides services to a population of 2.4 million spread out in the North Western Province and part of the Sabaragamuwa Province. This study was carried out to identify the pattern of all admissions to the A&E department of PGHK. Methods The prospective observational study was carried out from July 1, 2016, to June 30, 2017 (one year) to identify the pattern of admissions to the A&E department. Results There were 49,213 admissions to PGHK's A&E department during the study period. The average number of admissions was 135 (±17.9) per day. The percentage of deaths in the A&E department was 0.21%. The mean age of admitted patients was 46.7 (±21.7) years. A further 62% of admitted patients were males. The number of medical, surgical, paediatric, and gynaecological and obstetrical admissions was 55%, 42%, 3.5%, and 0.22%, respectively. Among the common emergency medical presentations, 34% were chest pain, 11% patients presented with unilateral weakness and/or slurring of speech, 10% covered dyspnoea, and 9% complained of dizziness/giddiness. Among emergency surgical presentations, 83% were trauma due to accidents, of which 27% were road-traffic-related accidents (RTAs). Discussion. The A&E department of PGHK provides services to a significantly high number of health emergencies every day. The majority of these admissions was due to chest pain and trauma related to accidents. The lower recorded number of paediatric and gynaecological and obstetrical emergencies presented to the A&E department is a result of a government policy mandating the admission of these types of patients directly to their respective wards. Further infrastructure development, staff recruitment, and training have to be planned and implemented to address the significantly high number of admissions to the A&E Department of PGHK.

Idiopathic Pulmonary Arterial Hypertension Unmasked by Pregnancy

A 31-year old woman presented to the acute medical unit 9 days post-partum with shortness of breath and peripheral oedema. Initially suspected to have either a pulmonary embolism or post-partum cardiomyopathy, she proceeded to have imaging including a CT Pulmonary angiogram and echocardiogram, which were suggestive of pulmonary hypertension and severe right heart failure. Her history and other investigations did not reveal any obvious cause for this. She was transferred to a specialist centre where she was diagnosed with Idiopathic Pulmonary Arterial Hypertension (IPAH), previously known as primary pulmonary hypertension. Shortness of breath during pregnancy and in the postpartum period is a relatively common acute medical presentation. Whilst IPAH is a rare diagnosis, it carries a high mortality rate, particularly in pregnancy, and requires prompt specialist investigation, diagnosis and management.

An acute presentation of haemophagocytic lymphohistiocytosis due to visceral leishmaniasis in a British adult returning traveller

A 62-year old British Caucasian woman normally resident in Spain presented with fever and pancytopaenia after returning to the UK. Her symptoms persisted despite broad-spectrum antibiotics, and she gradually became confused, hypotensive and progressively more pancytopaenic. Imaging demonstrated hepatosplenomegaly, and a bone marrow aspirate confirmed a diagnosis of haemophagocytic lymphohistiocytosis (HLH). Bone marrow polymerase chain reaction (PCR) and blood serology were both positive for Leishmania donovani, consistent with visceral leishmaniasis (VL). Following treatment with dexamethasone and amphotericin, she improved clinically and biochemically, and was able to return to Spain. Fever in the returning traveller is a common acute medical presentation. Although HLH and VL are rare diagnoses, both carry a very high mortality rate if undiagnosed and untreated.

Not quite a doctor, but should I help? A qualitative exploration of medical students’ attitudes towards responding to medical emergencies that occur in the public domain

ObjectiveTo explore medical students’ views on and experiences of responding to out-of-hospital medical emergencies.SettingUniversity College London (UCL).Participants11 UCL Medical School students.Study designQualitative.Methods and outcome measuresWe carried out 11 one-to-one semistructured...

P086: Emergency department visits for upper gastrointestinal bleeding: a population-based Alberta cohort

Introduction: Upper gastrointestinal bleeding (UGIB) is a common medical condition presenting to emergency departments (ED) and associated with substantial morbidity, mortality, and healthcare expenditures. Our aim was to evaluate the incidence of patients presenting to ED with UGIB in a large population-based surveillance cohort. Methods: The National Ambulatory Care Reporting System (NACRS) was used to identify all presentations to emergency departments for UGIB in Alberta from fiscal year 2010 to 2015 (n=56519) using the International Classification of Diseases Codes (ICD-10) in any diagnostic position. Baseline characteristics and UGIB incidence were calculated using descriptive statistics. Joinpoint regression models were used to calculate the average annual percent change (AAPC) with 95% confidence intervals (CI). Results: The median age of 56519 UGIB presentations was 56 years (interquartile range: 41 to 74 years), 56% were male, and 245% had at least one comorbidity. At time of disposition from the ED , 48.3% were admitted to or transferred to another hospital, 51.4% discharged, and 0.3% died in the emergency department. Further, 10.8% underwent upper endoscopy during their admission to the emergency department. The annual incidence of UGIB were 230.6 (2010), 232.8 (2011), 241.0 (2012), 242.2 (2013), 244.6 (2014), and 242.2 (2015) per 100,000 person-years. Between 2010 and 2015 the incidence of UGIB presenting to ED significantly increased overtime (AAPC=1.1; 95% CI: 0.3 to 2.0). Conclusion: UGIB is a common presentation to emergency departments and has been increasing overtime. Future studies are necessary to evaluate the underlying cause of UGIB and to determine its burden to Albertas healthcare system.

Training tomorrow’s doctors to explain ‘medically unexplained’ physical symptoms: An examination of UK medical educators’ views of barriers and solutions

ObjectiveCo-occuring physical symptoms, unexplained by organic pathology (known as Functional Syndromes, FS), are common and disabling presentations. However, FS is absent or inconsistently taught within undergraduate medical training. This study investigates the reasons for this and identifies potential solutions to improved implementation. MethodsTwenty-eight medical educators from thirteen different UK medical schools participated in semi-structured interviews. Thematic analysis proceeded iteratively, and in parallel with data production. ResultsBarriers to implementing FS training are beliefs about the complexity of FS, tutors’ negative attitudes towards FS, and FS being perceived as a low priority for the curriculum. In parallel participants recognised FS as ubiquitous within medical practice and erroneously assumed it must be taught by someone. They recommended that students should learn about FS through managed exposure, but only if tutors’ negative attitudes and behaviour are also addressed. ConclusionNegative attitudes towards FS by educators prevents designing and delivering effective education on this common medical presentation. Whilst there is recognition of the need to implement FS training, recommendations are multifaceted. Practice implicationsIncreased liaison between students, patients and educators is necessary to develop more informed and effective teaching methods for trainee doctors about FS and in order to minimise the impact of the hidden curriculum.

Deep Venous Thrombosis in Behcet's Syndrome: is Anticoagulation Necessary?

Deep vein thrombosis (DVT) in the lower extremities is a common medical presentation. Anticoagulation is the cornerstone of management. However, not all DVTs require anticoagulation. We report a case of DVT in a patient with Behcet's Syndrome where venous inflammation is the primary pathology and anti-inflammatory therapy is primary and the role of anti-coagulation is moot.

Individual and Medical Characteristics of Adults Presenting to an Urban Emergency Department in Ghana.

The aims of this study were to characterize the patients seeking acute care for injury and non-injury complaints in an urban Emergency Department in Ghana in order to 1) inform the curriculum of the newly developed Emergency Medicine resident training program 2) improve treatment processes, and 3) direct future community-wide injury prevention policies. A prospective cross-sectional survey of patients 18 years or older seeking care in an urban Accident and Emergency Center (AEC) was conducted between 7/13/2009 and 7/30/2009. Questionnaires were administered by trained research staff and each survey took 10-15 minutes to complete. Patients were asked questions regarding demographics, overall health and chief complaint. 254 patients were included in the sample. Participants' chief complaints were classified as either medical or injury-related. Approximately one third (38%) of patients presented with injuries and 62% presented for medical complaints. The most common injury at presentation was due to a road traffic injury, followed by falls and assault/fight. The most common medical presentation was abdominal pain followed by difficulty breathing and fainting/ blackout. Only 13% arrived to AEC by ambulance and 51% were unable to ambulate at the time of presentation. Approximately one-third of non-fatal adult visits were for acute injury. Future research should focus on developing surveillance systems for both medical and trauma patients. Physicians that are specifically trained to manage both the acutely injured patient and the medical patient will serve this population well given the variety of patients that seek care at the AEC.

Defending a traditional practice in the modern era: The use of lumbar puncture in the investigation of subarachnoid haemorrhage

Introduction. Acute severe headache is a common medical presentation, and a common area of diagnostic uncertainty. Subarachnoid haemorrhage (SAH) is the cause in a minority of patients and has a high rate of morbidity and mortality. Therefore, its conclusive diagnosis with computed tomography (CT) or lumbar puncture (LP) is paramount. With advancement in imaging technology, emerging evidence now suggests that LP is no longer required for a subset of patients as CT has 100% sensitivity in detecting SAH, when performed under specific conditions. Objectives. To assess the proportion of patients with conclusive CSF xanthochromia results following a negative CT scan in suspected SAH to determine the diagnostic efficacy of LP. Methods. CSF bilirubin and oxyhaemoglobin spectrophotometric absorbance data from all centres in a regional health board were identified for consecutive patients over a 6-month period. Results were stratified as conclusive (positive or negative), or inconclusive according to national guidelines. Results. 239 of 255 (93.7%) results were conclusive: 89.0% were negative (227 of 255). 4.7% of results were positive (12 of 255), revealing 4 cerebral aneurysms requiring treatment. 16 out of 255 (6.3%) samples were inconclusive, yielding 1 aneurysm requiring treatment. In the same period, there were 27 CT-positive cases of SAH. Conclusions. LP has a high diagnostic yield, eliminating the need for neurosurgical opinion or investigation in almost 90% of cases. The test is both cost and time efficient and subjects only a small number of patients to the radiation and contrast risks of angiography.

Acute chest pain in contingency operations at a Role 1 facility

Acute chest pain is a common medical presenting complaint which can be difficult to diagnose and treat outside of a fully equipped emergency department. In future contingency operations the number...

Comparison of capillary and venous blood glucose levels using glucometer and laboratory blood glucose level in poisoned patients being in coma.

Background:Poisoning is one of the most common medical presentations in a hospital. Hypoglycemic patients are at increased risk of toxicity. The purpose of this study was to compare capillary blood glucose and venous blood glucose measurements using glucometer against laboratory blood glucose in case of poisoned patients being in coma.Materials and Methods:During the 6-month study period, a random sample of 98 patients was admitted in the Department of Poisoning Emergency and Clinical Toxicology of Noor Hospital, Isfahan University of Medical Sciences, Iran from May 2010. Data collected included age, gender, poisoning reason, vital signs, and Glasgow Coma Scale. Capillary blood samples were obtained from the fourth fingertip of the non-dominant hand. t-Test, paired t-test, Pearson's correlation analysis, and one-way analysis of variance (ANOVA) were used for analysis.Results:The mean of capillary blood glucose was 115.7 ± 50.2, of venous blood glucose measured by glucose meter was 117.8 ± 47.3, and of glucose measured in vitro was 115.8 ± 55.1. Mean of blood glucose showed no significant difference with the three mentioned methods. The correlation between capillary and intravenous blood glucose samples measured by glucometer was 0.93, between capillary blood glucose and in vitro measured venous blood glucose was 0.78, and between venous blood glucose measured by glucose meter and in vitro measured sample was 0.81. The mean of capillary and venous blood glucose levels measured by glucose meter, capillary and venous blood glucose levels measured in vitro, and venous blood glucose levels measured by glucose meter had no significant differences.Conclusion:Using venous blood sample and measuring the glucose level in it by glucometer is an acceptable and advisable method, and capillary blood glucose measurement by using glucometer is not recommended for patients in coma.

Commercial Sexual Exploitation and Sex Trafficking of Children in the United States

Child commercial sexual exploitation and sex trafficking are global health problems requiring a multidisciplinary approach by individuals, organizations, communities, and national governments. The adverse emotional, physical, and social consequences for victims are legion and in many areas of the United States and the rest of the world, victim resources are scarce. Since violence, deprivation, abuse, and infection are so integral to the exploitation experience, victims may present for care to community and academic pediatric and adolescent health care providers. It is essential that medical professionals have the knowledge, skills, and resources to recognize victims, assess their needs, and treat them appropriately, including making key referrals for community services. However, to date medical information and resources regarding commercial sexual exploitation and sex trafficking has been sparse. There are no clinically validated screening tools specifically designed to identify victims in the health care setting and since victims seldom self-identify, it is likely that the majority of victims are unrecognized. The opportunity for comprehensive assessment and intervention is lost. Further, professionals receive little training on appropriate interview techniques for this special population, and many are ill equipped to ensure safety and optimal medical evaluation during the visit. This article provides a general overview of child sex trafficking and commercial sexual exploitation (CSEC), describing the epidemiology of international and domestic exploitation, and reviewing the challenges of conducting research on this population. The five stages of trafficking are explained, as are typical physical and emotional consequences of exploitation. The medical evaluation is described, including potential indicators of CSEC and sex trafficking, common medical presentations by victims, approaches to the comprehensive medical interview, and the appropriate medical exam with diagnostic testing and treatment. Finally, a discussion of common victim needs is provided, with a description of resources and referrals.

High Prevalence of Malaria Parasitemia and Anemia among Hospitalized Children in Rakai, Uganda

BackgroundThere is a paucity of data on malaria among hospitalized children in malaria endemic areas. We determined the prevalence, presentation and treatment outcomes of malaria and anemia among children in two hospitals in Rakai, Uganda.MethodsChildren under five years hospitalized in Kalisizo hospital or Bikira health center in Rakai district, Uganda between May 2011 and May 2012 were enrolled and followed-up until discharge, death or referral. Data were collected on social-demographic characteristics, current and past illnesses and clinical signs and symptoms. Blood smears, hemoglobin (Hgb) levels and HIV testing were performed from finger/heel prick blood. The associations between malaria infection and other factors were estimated using log-binomial regression to estimate adjusted prevalence risk ratios (aPRR) and 95% confidence intervals (CIs), controlling for clustering at health facilities.Results2471 children were enrolled. The most common medical presentations were fever (96.2%), cough (61.7%), vomiting (44.2%), diarrhea (20.8%), and seizures (16.0%). The prevalence of malaria parasitemia was 54.6%. Children with malaria were more likely to present with a history of fever (aPRR 2.23; CI 1.18–4.24) and seizures (aPRR 1.12; CI 1.09–1.16). Confirmed malaria was significantly lower among girls than boys (aPRR 0.92; CI 0.91–0.93), HIV infected children (aPRR 0.60 CI 0.52–0.71), and children with diarrhea (aPRR 0.76; CI 0.65–0.90). The overall prevalence of anemia (Hgb<10 g/dl) was 56.3% and severe anemia (Hgb<6 g/dL) was 17.8%. Among children with severe anemia 76.8% had malaria parasitemia, of whom 93.1% received blood transfusion. Malaria associated mortality was 0.6%.ConclusionThere was a high prevalence of malaria parasitemia and anemia among inpatient children under five years. Malaria prevention is a priority in this population.

An audit of first afebrile seizure management in an Irish tertiary pediatric setting

The objective of this study was to compare the first afebrile seizure management with internationally recognized standards in an Irish tertiary pediatric setting. Twenty-one management standards were derived from a combination of British (NICE 2004) and North American (AAN 2003) guidelines. Cases of first afebrile seizure presenting to a pediatric emergency department between July 2007 and June 2010 were assessed against the standards. On completion, the standards developed were presented to the relevant stakeholders, a nurse-developed parental advice sheet was introduced, and a re-audit was performed from July 2010 to June 2011. Forty children were identified in the initial audit period (A1) and 41 over the re-audit (A2). No case achieved full compliance with the devised standards in the audit period. A median compliance score of 15 (range 5-20) was achieved in A1 and 17 (range 11-21) in A2 [mean rank 31.93 versus 49.85; p(1,1) < 0.0001]. Optimal compliance (total score of ≥17) with devised standards was achieved in 6/40 patients in A1 and in 21/41 patients in A2 [χ (2) = 11.95; p(1,1) = 0.001]. We demonstrated an initial lack of compliance with international guidelines on management of a common medical presentation, first afebrile seizure, and demonstrated that improvements can be achieved by identification of appropriate standards and critical appraisal of the compliance with these standards through both formal and informal education.

'A terrible dream' - case of idiopathic pituitary insufficiency presenting as prolonged delirium in a rural hospital

A 75-year-old female presented to a rural hospital with prolonged delirium, and the diagnosis was idiopathic pituitary insufficiency. Delirium is a common medical presentation but diagnostic pathways can be challenging in rural practice. Delirium can be reversible if a treatable aetiology is detected.

Blackout and collapse

‘Collapse query cause’ is a common acute medical presentation with many different causes. This article focuses on syncope, which is caused by transient global cerebral hypoperfusion. There are four main sub-types of syncope, with neurally mediated and orthostatic syncope being by far the most common. Cardiac arrhythmias account for only 20% of all syncopal episodes. The initial evaluation is extremely important and leads to a diagnosis in around half of cases. Only some patients need investigation and those requested depend on the history, whether the person has structural heart disease, and whether the syncope is frequent or severe. The evaluation of syncope is often unstructured and varies considerably among doctors. The European Society of Cardiology guidelines on syncope are the standard for syncope specialists.