Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

This case study describes a patient who presented with vague visual complaints in the right eye, decreased visual acuity in the affected eye, and a difficult initial eye evaluation, including fundoscopic and slit lamp examinations, in the emergency department (ED). The preliminary finding included a darkened-appearing area of the retina on fundoscopic exam. The patient subsequently had bedside sonography of the eyes done by an emergency medicine (EM) intern which revealed a thin and serpentine strip appearing as a hyperechoic representation of the retina floating freely into the vitreous from the superior-lateral section of the posterior globe.

Non-traumatic abdominal pain is a common presenting complaint in emergency department (ED) patients, quoted in some contemporary literature as being the third most frequent reason for ED visits. We present the ED and hospital course of an unusual case of an 11 year old female with right lower quadrant abdominal pain. The admission assessment of this patient was “possible appendicitis versus gastroenteritis”; however, laparatomy revealed a right adnexal torsion. The need for emergency medicine physicians to always include gynecologic and other less common causes in the differential diagnosis and workup of abdominal pain in children is emphasized.

Objectives: To evaluate the frequency of peak expiratory flow rate (PEFR) measurement and clinical re-evaluation in the management of ED asthmatic patients. Methods: This was a retrospective chart review examining consecutive asthma patients who presented to the University of California Irvine ED between September 1, 2003 and December 31, 2003. Patients were excluded if they had a diagnosis of COPD, lung cancer, pneumonia, congestive heart failure, alpha 1 anti-trypsin deficiency or were under 5 years of age. Data collected included patient demographics, pulse oximetry reading(s), ED treatments rendered, and frequencies of PEFR measurement (pre and post therapy), of clinical re-evaluations in the ED, and of ED return visits. Results: Of the 122 ED visits from 111 patients, 11 (10%) patients returned during the 4 month study period, with 5 patients (4.5%) returning in less than 72 hours. Seven (6.0%) patients had PEFR done both pre and post treatment and 24 (20%) had one or more PEFR performed either before or after treatment. Only 61 (50%) of the visits had a documented clinical re-evaluation prior to disposition. Conclusions: Despite their documented role in asthma treatment algorithms, PEFR was performed infrequently and clinical re-evaluation was documented in only half of cases. Recommended algorithms for asthma management were not commonly followed in this academic ED.