Telemedicine can help to ensure that patients receive timely medical care.

We describe a case illustrating that telephone consultations can help to lower the psychological threshold for accessing medical care in people who are not aware of the seriousness of their symptoms, or who might otherwise be reluctant to access face-to-face care. A 69-year-old male patient called a teleconsultation service at the weekend because of acute fever. The patient was scheduled to have a hip replacement and the usual pre-operative check-up done the day before had been normal. However, a careful medical history taken during the teleconsultation revealed potentially serious symptoms. We therefore referred the patient to the emergency room immediately with the suspicion of severe infection, possibly due to colon cancer. The patient was subsequently diagnosed with septicaemia and adenocarcinoma of the sigmoid. This demonstrates that teleconsultation is not only a powerful tool for triage and diagnosis, but can also help to reduce delay in diagnosing severe diseases in primary health care.

Can airway obstruction be estimated by lung auscultation in an emergency room setting?

OBJECTIVE: Lung auscultation is a central part of the physical examination at hospital admission. In this study, the physicians' estimation of airway obstruction by auscultation was determined and compared with the degree of airway obstruction as measured by FEV(1)/FVC values. METHODS: Two hundred and thirty-three patients consecutively admitted to the medical emergency room with chest problems were included. After taking their history, patients were auscultated by an Internal Medicine registrar. The degree of airway obstruction had to be estimated (0=no, 1=mild, 2=moderate and 3=severe obstructed) and then spirometry was performed. Airway obstruction was defined as a ratio of FEV(1)/FVC <70%. The degree of airway obstruction was defined on FEV(1)/FVC as mild (FEV(1)/FVC <70% and >50%), moderate (FEV(1)/FVC <50% >30%) and severe (FEV(1)/FVC <30%). RESULTS: One hundred and thirty-five patients (57.9%) had no sign of airway obstruction (FEV(1)/FVC >70%). Spirometry showed a mild obstruction in 51 patients (21.9%), a moderate obstruction in 27 patients (11.6%) and a severe obstruction in 20 patients (8.6%). There was a weak but significant correlation between FEV(1)/FVC and the auscultation-based estimation of airway obstruction in Internal Medicine Registrars (Spearman's rho=0.328; P<0.001). The sensitivity to detect airway obstruction by lung auscultation was 72.6% and the specificity only 46.3%. Thus, the negative predictive value was 68% and the positive predictive value 51%. In 27 patients (9.7%), airway obstruction was missed by lung auscultation. In these 27 cases, the severity of airway obstruction was mild in 20 patients, moderate in 5 patients and severe in 2 patients. In 82 patients (29.4%) with no sign of airway obstruction (FEV(1)/FVC >70%), airway obstruction was wrongly estimated as mild in 42 patients, as moderate in 34 patients and as severe in 6 patients, respectively. By performing multiple logistic regression, normal lung auscultation was a significant and independent predictor for not having an airway obstruction (OR 2.48 (1.43-4.28); P=0.001). CONCLUSION: Under emergency room conditions, physicians can quite accurately exclude airway obstruction by auscultation. Normal lung auscultation is an independent predictor for not having an airway obstruction. However, airway obstruction is often overestimated by auscultation; thus, spirometry should be performed.

Diagnostic value of lung auscultation in an emergency room setting.

BACKGROUND: In daily routine, physicians use history, physical examination and technology-based information such as laboratory tests and imaging studies to diagnose the patients' disease. We determined the diagnostic value of lung auscultation in patients admitted to the Medical emergency room with chest symptoms. METHODS: Two-hundred-and forty-three consecutive patients (137 males), mean age 59.2 years were included. Internal Medicine registrars had to make a presumptive diagnosis, 1) after having taken the history and 2) after having auscultated the lungs. Thereafter, routine diagnostic procedures were performed. The estimated diagnosis was compared with the final diagnosis based on the written report to the Family Practitioner. RESULTS: Two-hundred-eighty-seven diagnoses were made. Eighteen percent of patients suffered from left heart failure, 13% from unexplained chest pain, 10.5% from chest wall pain, and 10.5% from pneumonia. Forty-one percent of the diagnoses were already correct when based only on the patient's history. Lung auscultation improved the diagnostic yield only in 1% and worsened it in another 3%. By multiple logistic regression, normal lung auscultation (OR 0.12 [95CI% 0.053-0.29]) was the independent predictor for not having a lung or heart disease. However, elevation of B-type natiuretic peptide (BNP) (OR 1.16 per 100 pg/ml (95CI% 1.004-1.35), wheezing (OR 0.023 [0.002-0.33]) and pCO2 (OR 0.25 (0.10-0.621) were independent predictors for having a heart disease, whereas wheezing (OR 7.41 [3.26-16.83]) and CRP (OR 1.008 per 10 units [1.003-1.014]) were risk factors for having a lung disease. CONCLUSION: In contrast to history taking, abnormal lung auscultation does not appear to contribute considerably to the final diagnosis in patients presenting with chest symptoms in an emergency room setting. However, normal lung auscultation is a valuable predictor for not having a lung or heart disease, whereas wheezing is a predictor for having a lung disease and not having a heart disease.