An unusual cause of tachycardia, hypotension, and intraabdominal free fluid: ovarian hyperstimulation syndrome

We report a case of ovarian hyperstimulation syndrome (OHSS) in a 37-year-old female who had recently underwent assisted reproductive technology involving oocyte retrieval. Her emergency department (ED) presentation, clinical course, and a discussion of ovarian hyperstimulation syndrome are also presented. Ovarian hyperstimulation syndrome is a critical diagnosis in emergency medicine, and emergency physicians must consider it in the differential for any female nontrauma patient presenting with hypotension, tachycardia, and abdominal pain.     

Adherence to highly active antiretroviral therapy

Case studies of three HIV-infected patients are presented that emphasize their struggles and attitudes toward the demands imposed by adherence to highly active antiretroviral therapy. The physicians who are treating these patients tried to select the most effective regimens within the limits of assumed adherence. When these patients were followed, the patients whom the physicians predicted would do poorly did well, while the more presumed competent patient did poorly. The discussion reinforces the unpredictability of choosing which patient will be able to live with complex daily medication schedules.     

Spontaneous globe subluxation in a patient with hyperemesis gravidarum: a case report and review of the literature

Globe subluxation, or anterior dislocation of the eyeball, is rarely encountered by emergency physicians. We report a case of subluxation of the globe secondary to severe vomiting followed by a discussion of globe subluxation, potential causes, procedure for reduction, and treatment for recurrent episodes. Early treatment by emergency physicians may prevent long-term complications and limit patient discomfort and anxiety.     

Live Conjoined Twins: A Rare First Trimester Diagnosis during Emergency Department Sonography

Background: The evaluation of vaginal bleeding and pelvic pain in the first trimester of pregnancy is an important component of emergency physician training. The increased use of bedside sonography by emergency physicians in the evaluation of these patients requires knowledge about the normal anatomy, variants, abnormal findings and their appearance on sonography. Objectives: To highlight the importance of a thorough pelvic and abdominal sonographic examination during a routine evaluation in the emergency department (ED). Case Report: We present the case of a patient found to have conjoined twins diagnosed by ED sonography. Conclusion: A discussion of the diagnosis, the findings on bedside sonogram and management options are presented.     

Acquired long QT syndrome secondary to cesium chloride supplement

The use of complementary medication is on the rise worldwide. More often than not, the treating physicians are unaware of this and also unfamiliar with the potential benefit or toxicity of the agents. Here, we present the case of a 39-year-old woman who presented with new onset of syncope as a result of acquired long QT syndrome secondary to taking a cesium chloride supplement. A brief discussion of the pathophysiology of this agent follows the case presentation.     

Ischemic renal disease: clinical course, prognosis, possibilities of treatment

The case presented for clinical discussion is a patient suffering from ischemic renal disease underlied by renal arterial artherosclerotic stenosis. The article demonstrates a leading role of diagnostic imaging and radiosurgical therapy (balloon dilatation and stenting), and a low effectiveness of conservative treatment.     

Physicians and the Hospice Decision: Awareness,Discussion, Reasons and Satisfaction

Two complementary studies examined dimensions of physicians’ involvement in the decision to enter hospice care. In Study 1, physicians practicing in three communities served by Medicare-certified hospices were surveyed by mail to determine their levels of awareness of hospice and the degree to which they discuss hospice with the terminally ill, and how these are affected by characteristics of their practice. Among the 45% who responded, over 90% were aware of hospice. In contrast, discussion of hospice was reported by only slightly over half. Nearly all comments about hospice (90%) were favorable. In Study 2, attending physicians of hospice patients were interviewed to determine their reasons for recommending hospice care, and their degrees of satisfaction with hospice. Aspects of support were identified as the most important reasons for recommending hospice; 97% of the physicians were satisfied with the decision that the patient enter hospice care. The gap between physicians’ awareness of hospice and their discussing it is examined, along with its implications. Issues for future research are identified.     

End-of-Life care: guidelines for patient-centered communication

When patients are diagnosed with cancer, primary care physicians often must deliver the bad news, discuss the prognosis, and make appropriate referrals. When delivering bad news, it is important to prioritize the key points that the patient should retain. Physicians should assess the patient's emotional state, readiness to engage in the discussion, and level of understanding about the condition. The discussion should be tailored according to these assessments. Often, multiple visits are needed. When discussing prognosis, physicians should be sensitive to variations in how much information patients want to know. The challenge for physicians is to communicate prognosis accurately without giving false hope. All physicians involved in the patient's care should coordinate their key prognosis points to avoid giving the patient mixed messages. As the disease progresses, physicians must reassess treatment effectiveness and discuss the values, goals, and preferences of the patient and family. It is important to initiate conversations about palliative care early in the disease course when the patient is still feeling well. There are innovative hospice programs that allow for simultaneous curative and palliative care. When physicians discuss the transition from curative to palliative care, they should avoid phrases that may convey to the patient a sense of failure or abandonment. Physicians also must be cognizant of how cultural factors may affect end-of-life discussions. Sensitivity to a patient's cultural and individual preferences will help the physician avoid stereotyping and making incorrect assumptions.     

Pandemic influenza: are we prepared to face our obligations?

After decades of low personal risk for contracting lethal diseases, physicians are suddenly facing the possibility of a substantial increase in occupational risk during an influenza pandemic. If they are not confronted before the onset of an influenza pandemic, feelings of unease and fear or ignorance about physicians' professional obligations could profoundly hinder individual physicians in fulfilling their professional duties. Such feelings could therefore undermine institutional and societal preparations. In their review published in Critical Care, Anantham and coworkers outline the ethical framework that forms the basis of the professional obligations of physicians who respond to health care emergencies, such as an influenza pandemic.     

Coma

The preceding discussion is an attempt to stress anatomy in the diagnosis of coma. By localizing the offending lesion, the physician can apply the appropriate diagnostic and therapeutic measures more adeptly. Because physicians are also frequently asked to prognosticate, I have tried to summarize the work of Plum and Posner in their study of the outcome of patients presenting in coma. The primary care physician is encouraged to plan at least for the basics in case he or she is faced with a comatose patient.     

Autopsy and grief: a case of transformative postmortem examination

BACKGROUND: A physician's obligations to deliver compassionate care do not end with a patient's death. When a patient dies there remains a responsibility to assist grieving family members. Unfortunately, many physicians feel ill prepared to assist in the bereavement process, not knowing what to say or how to say it. Although underutilized, the medical autopsy can play an important role in families' grief processes, particularly in those cases wherein uncertainties exist regarding the ultimate cause of death. DISCUSSION: Here we postulate a role for the medical autopsy in assisting families through the grief process, which we demonstrate via an illustrative case. Effective communication of these results to family members is the key to its therapeutic effect.     

Continuity of information in general practice

Objective - To investigate attitudes and experiences among general practitioners (GPs) taking part in an experiment with a list patient system in four municipalities in Norway. Design - A questionnaire distributed to all 160 GPs in the four municipalities after 3 years' trial of the system. Setting - Primary health care in Norway. Main outcome measures-The opinions of physicians on a list patient system after 3 years of trial. Results - Most of the physicians held that the list patient system imposed more obligations than they were used to. However, the majority also held that the system enhanced preconditions for doing a good professional job; 68% wanted the system on a permanent basis, while 14% rejected it. Conclusion - Positive aspects outweigh negative aspects in the attitude of GPs to a list patient system.     

Case report: a nursing challenge, the unstable pelvic fracture

A case report is presented that describes the initial care of a severely injured patient who was hemodynamically unstable. The discussion highlights the process used to recognize life-threatening injuries, to differentiate internal sources of hemorrhage, to provide damage-control surgery, and to stop further bleeding with an interventional radiologic examination. The emergency nursing care of a patient with unstable pelvic trauma is included.     

A study of the ethical sensitivity of physicians in Turkey

In order to prepare bioethics and clinical ethics courses for clinicians in Turkey, we needed to know the attitudes of physicians when placed in ethically difficult care situations. We presented four cases to 207 physicians who are members of the Physicians' Association in Kocaeli, Turkey. Depending on the decisions they made in each case, we determined whether they were aware of the ethical aspects of the cases and the principles they chose as a basis for their decisions. We aimed to gain information about their ethical tendencies and moral sensitivity. A small number of physicians stated that they would 'show respect for a patient's living will' in the first case, but more stated that they would 'let the patient refuse the treatment' in the second. In the third case, where medical confidentiality was the significant ethical issue, most of the physicians said that they would act in order to maintain confidentiality. For the last case, more than half the physicians chose to 'tell the truth' to the patient. The paternalism shown in the doctors' decisions on the first two cases was no longer observed in those made for the last two cases. We concluded that the physicians who participated in our study have low sensitivity to living wills (or advance directives) and patients refusing treatment. However, when issues of medical confidentiality and truth-telling are concerned, they take care to protect the autonomy of the individual an are relatively more aware of the ethical aspects of these cases.     

Interprofessional meetings in geriatric assessment units: a matter of care organization

Abstract

Inpatient geriatric assessment units (GAUs) exist in Quebec, Canada, to deliver comprehensive, integrated care to older vulnerable patients. Most cases should be discussed at interprofessional meetings (IMs), but research has shown this not to be so for 39% of GAU patients. Consequently, a study was undertaken to (1) describe GAU team composition and (2) identify GAU and patient characteristics associated with case discussion at IMs at least once during a patient’s stay. To this end, 877 hospitalization records from 44 GAUs were reviewed. Results showed most teams were composed of attending physicians, nurses, physical and occupational therapists, dietitians and social workers; 66% included clinical pharmacists and 43% liaison nurses. Multilevel modeling showed longer length of stay to be the strongest predictor of case discussion at an IM. Case discussion was also more likely for patients admitted via in- or inter-hospital transfer rather than via the emergency department, if the GAU included a liaison nurse, and if the GAU was not located in an urban area. In summary, case discussion at an IM depended more on how and where a patient was admitted than on the patient characteristics per se, suggesting that this is a matter of care organization.     

Tight-fitting garments as counterpressure devices

A case of traumatic splenic rupture in a hemodynamically stable elderly woman is presented. The patient decompensated almost immediately following the removal of a tight-fitting girdle. The implications of recognizing garments as potential counterpressure devices in emergency management are discussed. Emergency physicians are cautioned to carefully explore and reevaluate patients after the removal of tight-fitting garments.     

Gout: nonsteroidal anti-inflammatory drugs and colchicine to prevent painful flares during early urate-lowering therapy

A case report on a gout patient is presented with discussion of the use of prophylactic agents for prevention of gouty flare in such a patient when beginning urate-lowering therapy. The limitations of the literature on this subject are described. Advantages and disadvantages of of prophylaxis and the burden of pain are discussed.     

Error Identification, Disclosure, and Reporting: Practice Patterns of Three Emergency Medicine Provider Types

OBJECTIVES: To gather preliminary data on how the three major types of emergency medicine (EM) providers, physicians, nurses (RNs), and out-of-hospital personnel (EMTs), differ in error identification, disclosure, and reporting. METHODS: A convenience sample of emergency department (ED) providers completed a brief survey designed to evaluate error frequency, disclosure, and reporting practices as well as error-based discussion and educational activities. RESULTS: One hundred sixteen subjects participated: 41 EMTs (35%), 33 RNs (28%), and 42 physicians (36%). Forty-five percent of EMTs, 56% of RNs, and 21% of physicians identified no clinical errors during the preceding year. When errors were identified, physicians learned of them via dialogue with RNs (58%), patients (13%), pharmacy (35%), and attending physicians (35%). For known errors, all providers were equally unlikely to inform the team caring for the patient. Disclosure to patients was limited and varied by provider type (19% EMTs, 23% RNs, and 74% physicians). Disclosure education was rare, with 相似文献   

Physicians, firearm counseling, and legal liability

To explore the potential legal consequences to physicians of counseling their patients about gun violence, I consider the question: If a patient divests herself of a firearm upon the advice of her physician and is subsequently the victim of a rape, robbery, aggravated assault, or homicide, could she or her survivors argue convincingly that her physician was negligent? In attempting to answer this question, the four elements that a patient must establish to prevail in a malpractice action against a physician are discussed, and possible strategies for establishing them in the hypothetical case are explored. I conclude that plausible arguments can be made against the hypothetical physician engaged in firearm counseling as described. Conversely, physicians not engaging in discussions of gun safety face substantially lower liability risks.