Chief complaints and computed tomography results in the emergency department: a three-year retrospective cohort study.

BACKGROUND: Computed tomography (CT) is frequently performed in the patients who admitted to the emergency department (ED), discharged but returned to ED within 72 h. It is unknown whether the main complaints of patients assist physicians to use CT effectively. This study aimed to find the association between chief complaints and the CT results. METHODS: This three-year retrospective cohort study was conducted in the ED of a tertiary medical center. Adult patients who returned to the ED after the index visit were included from 2019 to 2021. Demographics, pre-existing diseases, chief complaints, and CT region were recorded by independent ED physicians. A logistic regression model with an odds ratio (OR) and 95% confidence interval (CI) was used to determine the relationship between chief complaints and positive CT results. RESULTS: In total, 7,699 patients revisited ED after the index visit; 1,202 (15.6%) received CT. The top chief complaints in patients who received CT were abdominal pain, dizziness, and muscle weakness. Patients with abdominal pain or gastrointestinal symptoms had a significantly higher rate of positive abdominopelvic CT than those without it (OR 2.83, 95% CI 1.98-4.05, p < 0.001), while the central nervous system and cardiopulmonary chief complaints were not associated (or negatively associated) with new positive CT findings. CONCLUSION: Chief complaints of patients on revisit to the ED are associated with different yields of new findings when CT scans of the chest, abdomen and head are performed. Physicians should consider these differential likelihoods of new positive findings based on these data.

When It's Not Allergic Rhinitis: Clinical Signs to Raise a Patient's Suspicion for Chronic Rhinosinusitis.

OBJECTIVE: To identify predictors of chronic rhinosinusitis (CRS) in patients presenting with the chief complaint of nasal allergies. STUDY DESIGN: Cross-sectional study. SETTING: Tertiary care, academic center. METHODS: Clinical and demographic characteristics were collected from participants who were patients presenting with the chief complaint of nasal allergies. From all participants, a 22-item Sinonasal Outcome Test (SNOT-22) was collected, and a modified Lund-Kennedy endoscopy score was calculated from nasal endoscopy. Association was sought between having CRS and variables of clinical and demographic characteristics, SNOT-22, and endoscopy score. RESULTS: A total of 219 patients were recruited and 91.3% were diagnosed with allergic rhinitis; 45.2% were also diagnosed with CRS. Approximately half of the patients with CRS reported no intranasal corticosteroid usage. Having CRS was associated with male sex (odds ratio [OR] = 2.29, 95% confidence interval [CI]: 1.30-4.04, P = .004), endoscopy score (OR = 1.96, 95% CI: 1.59-2.42, P < .001), and the SNOT-22 nasal subdomain score (OR = 1.07, 95% CI: 1.03-1.11, P = .001) related to SNOT-22 items: "need to blow nose," "thick nasal discharge," "sense of taste/smell," and "blockage/congestion of nose." At least moderate (item score ≥3) "blockage/congestion of nose" or "thick nasal discharge," mild "need to blow nose" (item score ≥2) or very mild decreased "sense of taste/smell" (item score ≥1), and any nasal endoscopy findings (endoscopy score ≥1) were statistically significant predictors of CRS. CONCLUSION: Moderate or more severe nasal obstruction or discharge symptoms, any decreased sense of smell/taste, or positive nasal endoscopy findings in patients believing they have allergic rhinitis should prompt further evaluation of CRS to avoid delays in treatment.

Evaluation of Age, Chief Complaint, Diagnosis, and Treatment Done during the First Dental Visit among Children in an Academic Dental Institution in Southern Kerala, India.

Context: A regular and timely first dental visit plays a cardinal role in the future oral health of the child. It is used to begin preventive and corrective interventions in dental care. Aim: To evaluate the age, chief complaint, diagnosis, and treatment done during the first dental visit among children in an academic dental institution in southern Kerala, India. Materials and Methods: A descriptive cross sectional retrospective survey was conducted between January and June 2022 among children in an academic dental institution in southern Kerala, India. The hospital records at the Pushpagiri College of Dental Sciences were examined to obtain the child's age, chief complaint, diagnosis, and treatment done during the first dental visit among children. Statistical Analysis: The data were expressed in frequencies and percentages. Results: The records of 1000 children (680 male and 320 female) were examined. Most children (40%) who came for their first dental visit were aged between 4 and 6 years. Only 16% of children aged 0-3 years came for their first dental visit. Pain and sensitivity (50%) and tooth decay (17%) were the most common chief complaints among children. Dental caries (45%) and pulpal pathology (38%) were the most common diagnoses among children. The most common treatments done were glass ionomer cement restorations (32%), followed by prescribing medications (29%). No treatment was required for 16% of the children. Only a minority (3%) of the children received preventive treatments. Conclusions: The first dental visit was delayed, and most children sought treatment only during apparent acute symptoms. There is a high prevalence of oral disease burden and underutilization of preventive dental care among children. Education of parents on the value of first dental visits and the usage of preventative dental care in children is crucial.

The Geospatial Analysis of Patients Seeking Dental Care at a Private Dental Institution in Chennai, India.

Background and aim Assessing the priority of the patient towards dental needs while considering the distance traveled by them is important to improve a dental service. The purpose of this study was to rank the patients' felt needs for dental care in the private dental institution in order of importance. The objective is to count the number of patients with various major complaints and compare how far patients traveled for various treatment plans tailored to their individual needs in a private dental institution. Material and methods The sample consisted of all new patients who sought dental care at Saveetha Dental College and Hospital, Chennai, India, between January 1, 2022, and December 31, 2022. Retrospective data from the dental information archive system was gathered on their primary chief complaint and residential address. Frequency distribution of patients with different chief complaints was found. The mean and standard deviation of distance traveled by patients for different treatment plans was done using descriptive statistics using IBM SPSS Statistics for Windows, Version 22 (Released 2013; IBM Corp., Armonk, New York, United States). Results The priority order of the felt need by the patients was dental pain in which n=1299 (15.4%) > missing teeth with n=1224 (14.59%) > deposit/stains/halitosis n=1149 (13.6%) > shaking tooth n=936 (11.15%) > irregularly placed/proclined teeth n=852 (10.15%) > dislodged crown/restoration n=843 (10.05%) > tooth decay/discoloration n=759 (9%) > general checkup n=723 (8.6%) > swelling/ulcer/wound n=246 (2.93%) > painful jaw/facial pain/difficult mouth opening n=198 (2.26%). In 2022, most patients requiring caries preventive measure (0.8%) located at the mean distance of 10.75±2.2 km, while patients requiring scaling (16.9%), dental filling (10.9%), endodontic management (18.6%), extraction (23.7%), prosthetic replacement (13.9%), orthodontic management (10.9%), and facial pain management (2.2%) were located at the mean distance of 14.49±8.2 km, 10.28±6.25 km, 18.43±13.9 km, 14.29±6.6 km, 23.49±11.8 km, 11.76±8.13 km, and 45.32±17.35 km, respectively. Conclusion More number of patients traveled long distances even more than 50 km for painful tooth decay. Also, lots of patients were found to seek replacement of their missing teeth next to pain. Thus, dental pain and missing teeth form a major priority of the patient's felt dental need. Also, the patient had traveled a lot for facial pain management compared to other treatment needs which shows the lack of facial pain management practice by dental care centers near their local residence.

Are 5-level triage systems improved by using a symptom based approach?-a Danish cohort study.

BACKGROUND: Five-level triage systems are being utilized in Danish emergency departments with and without the use of presenting symptoms. The aim of this study was to validate and compare two 5-level triage systems used in Danish emergency departments: "Danish Emergency Process Triage" (DEPT) based on a combination of vital signs and presenting symptoms and a locally adapted version of DEPT (VITAL-TRIAGE) using vital signs only. METHODS: This was a retrospective cohort using data from five Danish emergency departments. All patients attending an emergency department during the period of 1 April 2012 until 31 December 2015 were included. Validity of the two triage systems was assessed by comparing urgency categories determined by each triage system with critical outcomes: admission to Intensive care unit (ICU) within 24 h, 2-day mortality, diagnosis of critical illness, surgery within 48 h, discharge within 4 h and length of hospital stay. RESULTS: We included 632,196 ED contacts. Sensitivity for 24-h ICU admission was 0.79 (95% confidence interval 0.78-0.80) for DEPT and 0.44 (0.41-0.47) for VITAL-TRIAGE. The sensitivity for 2-day mortality was 0.69 (0.67-0.70) for DEPT and 0.37 (0.34-0.41) for VITAL-TRIAGE. The sensitivity to detect diagnoses of critical illness was 0.48 (0.47-0.50) for DEPT and 0.09 (0.08-0.10) for VITAL-TRIAGE. The sensitivity for predicting surgery within 48 h was 0.30 (0.30-0.31) in DEPT and 0.04 (0.04-0.04) in VITAL-TRIAGE. Length of stay was longer in VITAL-TRIAGE than DEPT. The sensitivity of DEPT to predict patients discharged within 4 h was 0.91 (0.91-0.92) while VITAL-TRIAGE was higher at 0.99 (0.99-0.99). The odds ratio for 24-h ICU admission and 2-day mortality was increased in high-urgency categories of both triage systems compared to low-urgency categories. CONCLUSIONS: High urgency categories in both triage systems are correlated with adverse outcomes. The inclusion of presenting symptoms in a modern 5-level triage system led to significantly higher sensitivity measures for the ability to predict outcomes related to patient urgency. DEPT achieves equal prognostic performance as other widespread 5-level triage systems.

Initial assessment in emergency departments by chief complaint and respiratory rate.

BACKGROUND: Understanding heterogeneity of the respiratory rate (RR) as a risk stratification marker across chief complaints is important to reduce misinterpretation of the risk posed by outcome events and to build accurate risk stratification tools. This study was conducted to investigate the associations between RR and clinical outcomes according to the five most frequent chief complaints in an emergency department (ED): fever, shortness of breath, altered mental status, chest pain, and abdominal pain. METHODS: This retrospective cohort study examined ED data of all adult patients who visited the ED of a tertiary medical center during April 2018-September 2019. The primary exposure was RR at the ED visit. Outcome measures were hospitalization and mechanical ventilation use. We used restrictive cubic spline and logistic regression models to assess the association of interest. RESULTS: Of 16 956 eligible ED patients, 4926 (29%) required hospitalization; 448 (3%) required mechanical ventilation. Overall, U-shaped associations were found between RR and the risk of hospitalization (eg, using RR = 16 as the reference, the odds ratio [OR] of RR = 32, 6.57 [95% CI 5.87-7.37]) and between RR and the risk of mechanical ventilation. This U-shaped association was driven by patients' association with altered mental status (eg, OR of RR = 12, 2.63 [95% CI 1.25-5.53]). For patients who have fever or shortness of breath, the risk of hospitalization increased monotonously with increased RR. CONCLUSIONS: U-shaped associations of RR with the risk of overall clinical outcomes were found. These associations varied across chief complaints.

Differences and similarities between emergency department syndromic surveillance and hospital discharge data for nonfatal drug overdose.

PURPOSE: Emergency department syndromic surveillance and hospital discharge data have been used to detect and monitor nonfatal drug overdose, yet few studies have assessed the differences and similarities between these two data sources. METHODS: The Centers for Disease Control and Prevention Drug Overdose Surveillance and Epidemiology system data from 14 states were used to compare these two sources at estimating monthly overdose burden and trends from January 2018 through December 2019 for nonfatal all drug, opioid-, heroin-, and stimulant-involved overdoses. RESULTS: Compared to discharge data, syndromic data captured 13.3% more overall emergency department visits, 67.8% more all drug overdose visits, 15.6% more opioid-involved overdose visits, and 78.8% more stimulant-involved overdose visits. Discharge data captured 18.9% more heroin-involved overdoses. Significant trends were identified for all drug (Average Monthly Percentage Change [AMPC]=1.1, 95% CI=0.4,1.8) and stimulant-involved overdoses (AMPC=2.4, 95% CI=1.2,3.7) in syndromic data; opioid-involved overdoses increased in both discharge and syndromic data (AMPCDischarge=0.9, 95% CI=0.2,1.7; AMPCSyndromic=1.9, CI=1.1,2.8). CONCLUSIONS: Results demonstrate that discharge data may be better for reporting counts, yet syndromic data are preferable to detect changes quickly and to alert practitioners and public health officials to local overdose clusters. These data sources do serve complementary purposes when examining overdose trends.

Comparison of Chief Complaints and Patient-Reported Symptoms of Treatment-Naive Lung Cancer Patients Before Surgery.

BACKGROUND: Lung cancer patients without chief complaints have been increasingly identified by physical examination. This study aimed to profile and compare chief complaints with patient-reported symptoms of lung cancer patients before surgery. METHODS: Data were extracted from a multicenter, prospective longitudinal study (CN-PRO-Lung 1) in China from November 2017 to January 2020. A comparison between chief complaints and patient-reported symptoms was analyzed using the Chi-squared test. RESULTS: A total of 201 (50.8%) lung cancer patients without chief complaints were found by physical examination at admission, and 195 (49.2%) patients had chief complaints. The top 5 chief complaints were coughing (38.1%), expectoration (25.5%), chest pain (13.6%), hemoptysis (10.6%), and shortness of breath (5.3%). There were significantly more patients with chief complaints of coughing (38.1% vs 15.0%, P <0.001) and pain (20.5% vs 6.9%, P<0.001) than those with the same symptoms rated ≥4 via MD Anderson Symptom Inventory‒Lung Cancer (MDASI-LC). There were less patients with chief complaints of fatigue (1.8% vs 10.9%, P<0.001), nausea (0.3% vs 2.5%, P=0.006), and vomiting (0.3% vs 1.8%, p=0.032) than those with the same symptoms rated ≥4 via MDASI-LC. In patients without chief complaints, the five most common moderate to severe patient-reported symptoms were disturbed sleep (19.5%), distress (13.5%), dry mouth (13%), sadness (12%), and difficulty remembering (11.1%). CONCLUSION: Symptoms of lung cancer patients not included in the chief complaint could be identified via a patient-reported outcome instrument, suggesting the necessity of implementing the patient-reported outcome assessment before lung cancer surgery for better patient care.

Somatic symptoms with psychogenic or psychiatric background: Characteristics and pitfalls.

INTRODUCTION: The characteristics of somatic symptoms seen at the first hospital visit in patients with psychogenic backgrounds remain poorly elucidated till date. METHODOLOGY: A total of 277 patients who visited the Department of General Medicine at a single university hospital with somatic symptoms were prospectively enrolled in this study. The eventual definite diagnoses were classified into the following three groups: non-psychogenic disease (n = 128), psychogenic symptoms (n = 131), and mental illness (n = 18). Subsequently, the chief complaints and other background information of the patient obtained at the first visit were compared among the three groups. RESULTS: More than half of the patient with non-psychogenic diseases (60.2%) presented with a single complaint at their first hospital visit; contrarily, less than half of the patients with psychogenic symptoms (23.7%) or mental illnesses (22.2%) presented with a single complaint at the first visit. Approximately, <10% of the patients with non-psychogenic diseases had four or more multisystemic presentations at the first visit. The results of the receiver operating characteristic curve analysis revealed a fair discriminatory ability of the number of complaints to identify patients with psychogenic diseases or psychiatric backgrounds. Almost half of the non-psychogenic patients with four or more multisystemic presentations were eventually diagnosed with autoimmune-related disorders, such as Sjögren's syndrome or Behçet's disease. In conclusion, the general notion that patients with psychogenic somatic symptoms are likely to present with more complaints than patients with non-psychogenic diseases is correct. However, not a few patients who present with multiple indefinite complaints would certainly have organic diseases such as autoimmune-related disorders or neuromuscular diseases. A careful diagnostic process is required in such patients before attributing their symptoms to psychogenic or psychiatric factors.

Calibrating a chief complaint list for low resource settings: a methodologic case study.

BACKGROUND: The chief or presenting complaint is the reason for seeking health care, often in the patient's own words. In limited resource settings, a diagnosis-based approach to quantifying burden of disease is not possible, partly due to limited availability of an established lexicon or coding system. Our group worked with colleagues from the African Federation of Emergency Medicine building on the existing literature to create a pilot symptom list representing an attempt to standardize undifferentiated chief complaints in emergency and acute care settings. An ideal list for any setting is one that strikes a balance between ease of use and length, while covering the vast majority of diseases with enough detail to permit epidemiologic surveillance and make informed decisions about resource needs. METHODS: This study was incorporated as a part of a larger prospective observational study on human immunodeficiency virus testing in Emergency Departments in South Africa. The pilot symptom list was used for chief complaint coding in three Emergency Departments. Data was collected on 3357 patients using paper case report forms. Chief complaint terms were reviewed by two study team members to determine the frequency of concordance between the coded chief complaint term and the selected symptom(s) from the pilot symptom list. RESULTS: Overall, 3537 patients' chief complaints were reviewed, of which 640 were identified as 'potential mismatches.' When considering the 191 confirmed mismatches (29.8%), the Delphi process identified 6 (3.1%) false mismatches and 185 (96.9%) true mismatches. Significant chief-complaint clustering was identified with 9 sets of complaints frequently selected together for the same patient. "Pain" was used 2076 times for 58.7% of all patients. A combination of user feedback and expert-panel modified Delphi analysis of mismatched complaints and clustered complaints resulted in several substantial changes to the pilot symptom list. CONCLUSIONS: This study presented a systematic methodology for calibrating a chief complaint list for the local context. Our revised list removed/reworded symptoms that frequently clustered together or were misinterpreted by health professionals. Recommendations for additions, modifications, and/or deletions from the pilot chief complaint list we believe will improve the functionality of the list in low resource environments.

Prevalence and factors influencing reporting of true periodontal chief complaints: A retrospective analysis.

OBJECTIVES: To investigate the prevalence of true periodontal chief complaints (CC) and the factors affecting their reporting by patients with periodontal diseases (PD). MATERIALS AND METHODS: This cross-sectional study was based on retrospective analysis of available periodontal records. Different personal and demographic variables were obtained from these records including CC, age, gender, working status, past medical/dental history, smoking status and diagnosis. In addition, clinical parameters of plaque index, gingival index, probing pocket depth (PPD), and number of missing teeth. Periodontal CC were retrieved and divided either into true periodontal (bleeding, tooth mobility, and alteration in gingival color/shape) or others (emergency and esthetic-related) CC. RESULTS: A total of 1161 records were included in the final analysis. Results showed that only 287 (24.7%) of patients reported true periodontal CC whereas the remaining 874 (75.3%) patients were not aware about symptoms of PD. Regression modeling indicated that reporting of true CC was positively associated with smoking and PPD but negatively associated with number of missing teeth and gender (male). CONCLUSIONS: Results suggested that recognition of true periodontal CC by the patients was low. Reporting of true periodontal CC was significantly associated with smoking, PPD, female and lower number of missing teeth. These results shed light on the importance of increasing public knowledge about PD which is essential to aid people in recognizing these diseases at early stages.

Characterizing COVID-19: A chief complaint based approach.

BACKGROUND: The COVID-19 pandemic has inundated emergency departments with patients exhibiting a wide array of symptomatology and clinical manifestations. We aim to evaluate the chief complaints of patients presenting to our ED with either suspected or confirmed COVID-19 to better understand the clinical presentation of this pandemic. METHODS: This study was a retrospective computational analysis that investigated the chief complaints of all confirmed and suspected COVID-19 cases presenting to our adult ED (patients aged 22 and older) using a variety of data mining methods. Our study employed descriptive statistics to analyze the set of complaints that are most common, hierarchical clustering analysis to provide a nuanced way of identifying complaints that co-occur, and hypothesis testing identify complaint differences among age differences. RESULTS: A quantitative analysis of 5015 ED visits of COVID-suspected patients (1483 confirmed COVID-positive patients) identified 209 unique chief complaints. Of the 209 chief complaints, fever and shortness of breath were the most prevalent initial presenting symptoms. In the subset of COVID-19 confirmed positive cases, we discovered seven distinct clusters of presenting complaints. Patients over 65 years of age were more likely to present with weakness and altered mental status. CONCLUSIONS: Our research highlights an important aspect of the evaluation and management of COVID-19 patients in the emergency department. Our study identified most common chief complaints, chief complaints differences across age groups, and 7 distinct groups of COVID-19 symptoms. This large-scale effort to classify the most commonly reported symptoms in ED patients provides public health officials and providers with data for identifying COVID-19 cases.

Validation of chief complaints, medical history, medications, and physician diagnoses structured with an integrated emergency department information system in Japan: the Next Stage ER system.

AIM: Emergency department information systems (EDIS) facilitate free-text data use for clinical research; however, no study has validated whether the Next Stage ER system (NSER), an EDIS used in Japan, accurately translates electronic medical records (EMRs) into structured data. METHODS: This is a retrospective cohort study using data from the emergency department (ED) of a tertiary care hospital from 2018 to 2019. We used EMRs of 500 random samples from 27,000 ED visits during the study period. Through the NSER system, chief complaints were translated into 231 chief complaint categories based on the Japan Triage and Acuity Scale. Medical history and physician's diagnoses were encoded using the International Classification of Diseases, 10th Revision; medications were encoded as Anatomical Therapeutic Chemical Classification System codes. Two reviewers independently reviewed 20 items (e.g., presence of fever) for each study component (e.g., chief complaints). We calculated association measures of the structured data by the NSER system, using the chart review results as the gold standard. RESULTS: Sensitivities were very high (>90%) in 17 chief complaints. Positive predictive values were high for 14 chief complaints (≥80%). Negative predictive values were ≥96% for all chief complaints. For medical history and medications, most of the association measures were very high (>90%). For physicians' ED diagnoses, sensitivities were very high (>93%) in 16 diagnoses; specificities and negative predictive values were very high (>97%). CONCLUSIONS: Chief complaints, medical history, medications, and physician's ED diagnoses in EMRs were well-translated into existing categories or coding by the NSER system.

Generating contextual embeddings for emergency department chief complaints.

OBJECTIVE: We learn contextual embeddings for emergency department (ED) chief complaints using Bidirectional Encoder Representations from Transformers (BERT), a state-of-the-art language model, to derive a compact and computationally useful representation for free-text chief complaints. MATERIALS AND METHODS: Retrospective data on 2.1 million adult and pediatric ED visits was obtained from a large healthcare system covering the period of March 2013 to July 2019. A total of 355 497 (16.4%) visits from 65 737 (8.9%) patients were removed for absence of either a structured or unstructured chief complaint. To ensure adequate training set size, chief complaint labels that comprised less than 0.01%, or 1 in 10 000, of all visits were excluded. The cutoff threshold was incremented on a log scale to create seven datasets of decreasing sparsity. The classification task was to predict the provider-assigned label from the free-text chief complaint using BERT, with Long Short-Term Memory (LSTM) and Embeddings from Language Models (ELMo) as baselines. Performance was measured as the Top-k accuracy from k = 1:5 on a hold-out test set comprising 5% of the samples. The embedding for each free-text chief complaint was extracted as the final 768-dimensional layer of the BERT model and visualized using t-distributed stochastic neighbor embedding (t-SNE). RESULTS: The models achieved increasing performance with datasets of decreasing sparsity, with BERT outperforming both LSTM and ELMo. The BERT model yielded Top-1 accuracies of 0.65 and 0.69, Top-3 accuracies of 0.87 and 0.90, and Top-5 accuracies of 0.92 and 0.94 on datasets comprised of 434 and 188 labels, respectively. Visualization using t-SNE mapped the learned embeddings in a clinically meaningful way, with related concepts embedded close to each other and broader types of chief complaints clustered together. DISCUSSION: Despite the inherent noise in the chief complaint label space, the model was able to learn a rich representation of chief complaints and generate reasonable predictions of their labels. The learned embeddings accurately predict provider-assigned chief complaint labels and map semantically similar chief complaints to nearby points in vector space. CONCLUSION: Such a model may be used to automatically map free-text chief complaints to structured fields and to assist the development of a standardized, data-driven ontology of chief complaints for healthcare institutions.

Age Differences in the Chief Complaint Associated With a First Acute Myocardial Infarction and Patient's Care-Seeking Behavior.

BACKGROUND: This study set out to describe age differences in patient's chief complaint related to a first myocardial infarction and how the "typicality" of patient's acute symptoms relates to extent of prehospital delay. METHODS: The medical records of 2586 residents of central Massachusetts hospitalized at 11 greater Worcester medical centers with a first myocardial infarction on a biennial basis between 2001 and 2011 were reviewed. RESULTS: The average age of the study population was 66.4 years, 39.6% were women, 40.2% were diagnosed with a ST-elevation myocardial infarction (STEMI), and 72.0 % presented with typical symptoms of myocardial infarction, namely acute chest pain or pressure. Patients were categorized into 5 age strata: >55 years (23%), 55-64 years (20%), 65-74 years (19%), 75-84 years (22%), and ≥85 years (16%). The lowest proportion (11%) of atypical symptoms of myocardial infarction was observed in patients <55 years, increasing to 17%, 28%, 40%, and 51% across the respective age groups. The most prevalent chief complaint reported at the time of hospitalization was chest pain, but the proportion of patients reporting this symptom decreased from the youngest (83%) to the oldest patient groups (45%). There was a slightly increased risk of prehospital delay across the different age groups (higher in the oldest old) in those who presented with atypical, rather than typical, symptoms of myocardial infarction. CONCLUSIONS: The present results provide insights to the presenting chief complaint of patients hospitalized with a first myocardial infarction according to age and the relation of symptom presentation to patient's care-seeking behavior.

Delays in recognition of the need for telephone-assisted CPR due to caller descriptions of chief complaint.

BACKGROUND: The objective of this study was to test if caller descriptions of chief complaint delays emergency medical dispatchers' (EMDs) recognition of the need for telephone-assisted CPR (T-CPR). METHODS: We conducted an analysis of N = 433 cardiac arrest calls from six large call centers in the United States. Calls were abstracted for initial chief complaint description: caller reports (1) correct medical condition (CMC); (2) incorrect medical condition (IMC), or (3) signs/symptoms only (SS), as well the time interval between call pickup and recognition of the need for T-CPR. In addition, we abstracted if EMDs asked questions related to the caller's chief complaint (rather than, or before), asking about patients' consciousness and breathing status. RESULTS: The majority of cardiac arrest calls (60%) were reported as SS. Median time to recognition of the need for T-CPR was 64 s for SS chief complaints, 47 s for CMC chief complaints, and 100 s for IMC chief complaints. EMDs pursued chief complaint descriptions for 9% of the calls with SS chief complaints, 41% of the calls with IMC chief complaints, and 19% of the calls with CMC chief complaints. Median time to recognition of the need for CPR for calls in which the chief complaint description was pursued was 166 s compared to 62 s for calls in which the chief complaint description was not pursued. CONCLUSION: Caller chief complaint description affects the time to recognition of the need for T-CPR. CLINICAL TRIAL REGISTRATION: http://www.clinicaltrials.gov Trial # NCT01972087.

Comparison of the clinical characteristics of TAFRO syndrome and idiopathic multicentric Castleman disease in general internal medicine: a 6-year retrospective study.

BACKGROUND: Although thrombocytopenia, anasarca, fever, reticulin fibrosis and organomegaly (TAFRO) syndrome was first described as a variant of idiopathic multicentric Castleman disease (CD), patients with TAFRO syndrome demonstrate more aggressive clinical features. Because these patients may present with fever of unknown origin, general physicians need to recognise its characteristic laboratory data and clinical features during hospitalisation. AIMS: to describe the features, symptoms and characteristics of TAFRO syndrome and to compare them to those of idiopathic CD. METHODS: This was a retrospective study of patients with histopathologically confirmed TAFRO syndrome and idiopathic multicentric CD who were diagnosed and managed between April 2012 and June 2018 in a Japanese university hospital's General Medicine Department. RESULTS: We found that the hospitalisations were significantly longer among patients with TAFRO syndrome compared to those with idiopathic CD (median: 87 days; range: 34-236 days vs median: 30 days; range: 13-59 days; P < 0.01). Patients with TAFRO syndrome were more likely to present with fever, abdominal pain and elevated inflammatory markers and be misdiagnosed with an infectious disease during the first hospital visit. Approximately 40% of patients with TAFRO syndrome had no radiographically enlarged lymph nodes. CONCLUSIONS: TAFRO syndrome may present as an infectious disease with an aggressive clinical course. Our study highlights the importance of giving significance to chief complaints and laboratory data. Physicians need to recognise the clinical and laboratory features of this disease to avoid missing this potentially fatal disorder.

Homeless patients tend to have greater psychiatric needs when presenting to the emergency department.

INTRODUCTION: Homeless patients tend to visit Emergency Departments (EDs) more frequently than the non-homeless population. The goal of this study was to assess differences in chief complaint, medical conditions, and disposition between homeless patients compared to non-homeless patients presenting to an urban ED. METHODS: This was a retrospective cohort of homeless patients ages ≥18 years compared to non-homeless controls from January 1, 2017 to December 31, 2017. Exclusion criteria were as follows: direct admission to hospital floor, repeat visits, or leaving without being seen. The primary endpoint of this study was to assess differences in chief complaint of homeless versus non-homeless patients upon presentation to the ED. Our secondary endpoints included differences in ED utilization between the two groups, in terms of length of stay, ambulance use, diagnosis, and disposition. RESULTS: Homeless patients were more likely present to the ED for a psychiatric evaluation (homeless group 34% vs. non-homeless group 4%, p < 0.01) and have a history of a psychiatric diagnosis (56% vs. 10%, p < 0.01) compared to non-homeless controls. Homeless patients also tended to require more ambulance transport (46% vs. 16%, p < 0.01). More homeless patients were transferred to a psychiatric facility (40% vs. 1%, p < 0.01), while the majority of non-homeless patients were discharged home (50% vs. 93%, p < 0.01). CONCLUSION: This study found that homeless patients had a significantly higher association with psychiatric diagnoses and greater ED utilization than non-homeless. This suggests the importance of increased access to consistent psychiatric care and follow up within the homeless population.

Using the Chief Complaint Driven Medical History: Theoretical Background and Practical Steps for Student Clinicians.

This article was migrated. The article was marked as recommended. A previous short report presented an approach to teaching a focused medical history in the emergency department by using a chief complaint directed differential diagnosis guided streamlined series of questioning. It was proposed that such an approach teaches clinical expertise. The current article presents a review of a robust literature in the acquisition of cognitive expertise, and specifically how novices become experts through the acquistion of increasingly relevant and pertinent information. The review traces the development of several concepts such as exemplars illness scripts, problem representations, the use of semantic qualifiers and shows how the current proposed method incorporates those approaches. The method is applied specifically to two patient chief complaints commonly encountered in the emergency deparment and suggests how this approach would be useful in developing diagnostic ability in student physicians.