Probability of appendicitis before and after observation.

STUDY OBJECTIVE: To examine patients with abdominal pain for changes in probability of appendicitis during observation. STUDY DESIGN: Retrospective cohort study. SETTING: University-affiliated community hospital. METHODS: 252 patients with abdominal pain who were examined underwent short-term (10.4 hours) observation (95% confidence interval [CI], 8.7, 12.1) before the decision to operate during a one-year period. Alvarado's scoring system and a probability-of-diagnosis nomogram were used to assign scores and estimate probability of appendicitis. MEASUREMENTS AND RESULTS: In the study group, mean score of patients with appendicitis increased after observation from 6.8 (95% CI, 6.2, 7.4) to 7.8 (95% CI, 7.3, 8.3), corresponding to a change in probability of appendicitis from 50% to 65%. Mean score of patients without appendicitis decreased from 3.8 (95% CI, 3.5, 4.1) to 1.6 (95% CI, 1.58, 1.62), corresponding to a change in probability from 35% to 22%. The difference between mean scores for patients with and without appendicitis increased from 2.6 (95% CI, 2.0, 3.2) to 6.2 (95% CI, 6.15, 6.25) during observation. The study group initially had intermediate probability of appendicitis (score, 4.35; 95% CI, 4.04, 4.66) compared with high probability for patients who went directly to surgery after their initial evaluation (63 patients; score, 7.59; 95% CI, 7.05, 8.73) and low probability for patients with abdominal pain who were sent home after their initial evaluation without observation or surgery (2,097 patients; score, 1.87; 95% CI, 1.48, 2.26). CONCLUSION: In this group of patients with intermediate initial probability of appendicitis, observation improved the ability to distinguish patients with from those without appendicitis.

Mitral and tricuspid valve rupture from blunt trauma sustained during a motor vehicle collision.

The incidence of mitral valve injury resulting from blunt trauma is low. This report presents the case of a 36-year-old male who survived the rupture of both his mitral and tricuspid valves after striking the steering wheel during a motor vehicle accident. Echocardiograms were used to make the diagnosis.

The observable patient in the DRG era.

We examined financial differences of observing patients in the acute care hospital versus an emergency department observation unit. We identified 193 patients who could have been treated in either the acute care hospital or observation unit. Under a cost reimbursement system, the charge per patient was +197 greater, the reimbursement per patient was +254 greater, and the profit per patient was +140 greater for observing patients in the hospital rather than in the observation unit (p less than 0.001). Under a prospective payment system, the charge per patient was +1187 greater, the reimbursement per patient was +1137 greater, and the profit per patient was +1063 greater for observing patients in the hospital rather than in the observation unit (p less than 0.001). This difference in reimbursement can be a great financial incentive for hospitals to admit patients rather than to observe them in the emergency department. Significant savings might be realized for the health care payer by optimal use of observation units under a prospective payment or cost reimbursement system.

An unusual presentation of spontaneous pneumomediastinum.

Spontaneous pneumomediastinum is an uncommon disease that often presents with subtle clinical and radiographic findings. During a two-week period, three patients presented with complaints of throat and neck pain. The first complained of difficulty swallowing and throat and chest discomfort; accurate diagnosis was delayed because of the unusual presenting symptoms. The second had severe throat pain. The third presented with unstable vital signs, throat and neck pain, and air in the pericardium and mediastinum. Review of the first case facilitated the correct diagnosis of spontaneous pneumomediastinum in the subsequent cases. All three patients were discharged free of symptoms.

Left tension pneumothorax masquerading as anterior myocardial infarction.

Spontaneous pneumothorax is an emergency that can present with variable signs and symptoms. Diagnosis of pneumothorax can be difficult, particularly in patients who present with unusual clinical findings. The electrocardiographic changes that develop with left pneumothorax are not widely known and can mimic acute myocardial ischemia. Our patient was admitted to the Cardiovascular Intensive Care Unit because of characteristic changes on the electrocardiogram. An admission chest film revealed left tension pneumothorax.

Gastrointestinal disease associated with meningococcemia.

Despite the multiple organ involvement seen in meningococcal disease, there is little in the literature to support gastrointestinal symptoms as the predominant finding. In the past year four patients with meningococcemia and meningitis presented with gastrointestinal symptoms. In three cases the gastrointestinal findings were of such severity that the diagnosis of meningococcemia was obscured.