Utility of the ED Pelvic Exam: Results of a Prospective Pilot Study
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ED patients presenting with NSAP. Subjects underwent prompted history and physical examination including rectal examination and stool occult blood testing, a standard battery of laboratory studies, acute abdominal series radiographs and non-contrast helical computed tomography. Subjects were followed up to six months for ultimate diagnosis and outcome. Statistical analysis: Standard contingency table and chi-square analysis were performed in order to determine sensitivity, specificity, positive and negative likelihood ratios, and significance of positive and negative findings in predicting UI diagnosis. Results: Results of stool gross- and occult-blood examination obtained from rectal examination were available for 152 subjects. Colorimetric quality control analysis was performed on all occult blood tests - all were positive. Of the subject samples, one was positive for gross blood, and had a final diagnosis of diverticulitis requiring hospital admission (coded UI C ). Of the remaining 151 subjects, 15 were positive for occult blood, of which 9 required UI (true positive rate 60%). Ultimate diagnoses included adenocarcinoma of the colon (2), appendicitis (2), diverticulitis, ulcerative colitis, small bowel obstruction, ileus and obstructive pancreatitis. Of the 136 occult-negative subjects, 55 required UI (false negative rate 40%). Contingency table analysis of stool occult blood as a predictor of UI yielded the following: sensitivity .14, specificity .93, LR C2.04, LR- .92. Chi-square analysis yielded a result of 1.48, with 2 degrees of freedom, yielding a p \ 0.48 (insignificant). Conclusion: The presence of gross- or occult-blood in the tool samples of NSAP patients tended to be weakly predictive of the need for UI. A negative result was of no diagnostic value. Given that stool samples for analysis may be obtained easily by digital rectal examination, rectal thermometer probe or swab, continuation of this practice as a rapid bedside screen for potentially life-threatening conditions in patients presenting with NSAP appears to be indicated. 130 Utility of the ED Pelvic Exam: Results of a Prospective Pilot Study Brown J, Aristizabal J, Nicoll K, The George Washington University, Washington, DC; The George Washington University School of Medicine, Washington, DC Study Objectives: Most standard emergency medicine texts emphasize the importance of performing a pelvic exam on any female patient with abdominal pain or vaginal bleeding. The utility of this exam has never been prospectively evaluated, despite the fact that this exam may be physically and emotionally painful for the female patient. We sought to determine the utility of performing the exam in this population of emergency department patients. Methods: In a large academic emergency department, female patients undergoing a pelvic exam and the physicians caring for them were approached by trained research assistants. Research assistants enrolled consecutive patients 16 hours a day over a three month period. After informed consent from both patient and provider, demographics were collected as well as the results of the general physical exam. Prior to performing the pelvic exam, the health care provider was asked to predict the results. The actual findings of the exam were compared with the predicted findings. Results of laboratory and radiographic tests were also correlated with the predicted and actual findings of the pelvic exam. Results: Ninety-one patients were prospectively entered into the study. The mean age was 30 with a range of 18-55 years. The most common presenting symptoms were abdominal pain (n=65, 71%), vaginal bleeding (n= 41, 45%), side pain (n=21, 23%), nausea (n=21, 23%), and vaginal bleeding (n=14, 15%). Twelve patients (13%) were pregnant. The exam was performed 16% of the time by medical students (n=14), 14% of the time by interns (n=12), and 69% of the time by residents (n=63). Thirty-six (39%) of the examining physicians were EM residents. The most common reasons for performing the pelvic exam were: to assess for adnexal tenderness (n=44, 48%), to assess the os and check for ongoing uterine bleeding (n=38, 42%), to evaluate for cervical motion tenderness (n=36, 39%), to look for a discharge (n=31, 34%) or products of conception (n=18, 20%), or to evaluate for uterine tenderness (n=25, 27%). When compared with predicted findings, the pelvic exam was as expected in 62 patients (68%). In a further 25 patients (27%), the findings of the pelvic exam were not as predicted, but resulted in no change in the clinical plan. In only 4 cases (4%), did the exam reveal a finding that was both unexpected and changed the clinical plan. One of these four patients was admitted. Review of this case showed the patient was admitted for a urinary tract infection, and not because of any findings on physical exam. Of the 4 patients who were admitted (4%), two patients had a pelvic exam that revealed unexpected results, and only one of these caused the physician to change the care planned for the patient. Conclusion: In over 95% of patients, the results of the pelvic exam were predictable. Further research should be conducted to determine the predictive factors that may allow a pelvic exam to be safely deferred. 131 Influence of Sex on the Management of Appendicitis Crystal CS, Howland TR, Skinner CG, Miller MA, Coon TP, Darnall Army Community Hospital, Fort Hood, TX Study Objectives: The influence of sex on the management of appendicitis has been well hypothesized. We sought to evaluate the management of appendicitis in a military community hospital with a predominantly male population and determine the influence of sex on the ordering of CT, CT test characteristics, negative laparotomy rate, and perforation rate. Methods: A retrospectrive chart review was performed on all charts with a final diagnosis of appendicitis or perforated appendicitis at an academic military community emergency department (60,000 visits per year) between January 1 and December 31, 2004. The hospital’s computerized tracking system was used to identify final diagnoses. Appendectomy patients never seen in the ED, and patients that had a normal appendix removed during other surgical exploration were excluded from the study. Medical records were reviewed by two physicians each blinded to the patient’s final diagnosis. Data regarding age, sex, whether a CT was performed or not, and radiologist interpretation (negative, positive, or indeterminant) was recorded on a standard data collection form. Pathology results were then reviewed and recorded as appendicitis, perforated appendicitis, or normal appendix. Percentages were calculated for the total patient population, males, and females for the ordering of CT, negative laporatomy rate, and perforation rate. The sensitivity of CT was also calculated by sex. Results: 109 appendectomies for suspected appendicitis were performed during the study period with 90 patients having pathology confirmed appendicitis. There were 69 male and 40 female patients total. Eighty patients had a CT ordered and sex did not influence ordering (71% male vs. 77.5% female; p=0.460). CT had an overall sensitivity of 88.4% (90.5% male and 85.2% for female). The total rate of negative laparotomies was 17.4% with no difference between males and females (18.8% vs. 15%; p=0.610). When comparing negative lap rates for patients receiving CT or not there was no difference for females or total patients; however, male patients not receiving CT had a significantly higher negative laparotomy rate when compared to males receiving a CT (30.0% vs. 14.3%; p=0.027). 17 patients (15.6%) in our study had a perforated appendix, 11 male and 6 female (p=0.896) (see Table). Conclusion: Sex had no influence on the ordering of CT, negative laparotomy rate, or perforation rate at our predominately male population community hospital. CT sensitivity was similar between males and females and the ordering of CT did not alter the overall negative lap rate. However, the negative lap rate was significantly higher in males not receiving a CT when compared to males receiving a CT. 132 ED Presentation of Dyspnea in HF Patients Results in Increased Hospital Stay and Medication Costs Milzman DP, Ennis J, Barbaccia J, Davis G, Gebreyes K, Madan S, Washington Hospital Center, Washington, DC Objectives: Correctly identifying Decompensated Heart Failure (DHF) as the cause of dyspnea during ED presentation has been assumed to be fairly routine. This Study will evaluate initial treatments of attending EPs on confirmed HF patients without any markers to aid proper diagnoses such as BNP. Methods: Consecutive patients presenting to an urban teaching ED were reviewed at discharge for a primary diagnoses of Heart Failure: ‘DRG 127’. The study included all DHF patients admitted directly through the ED Patients receiving antibiotics during the ED care period were compared to all other DHF patients based on outcomes and costs at hospital discharge. Results: There were a total of 2,413 patients presenting directly to the ED and receiving a primary discharge diagnoses of HF (DRG 127). Further analysis for any infectious causation and need for antibiotic treatment based on chart review and discharge diagnosis reduced the total number of patients to 1,946. 1,461 did not receive antibiotic(AB) and 485 DHF patients received extended spectrum AB in the ED based on preliminary diagnosis attributed to either pneumonia or bronchitis based on complaints and initial CXR read by EP. 78% of DHF patients had SOB and/or CP as triage chief complaint, none had fever and \5% had coughing or leg swelling. The total hospital days for the antibiotic treatment group were 5.2 days compared to the DHF group without initial AB of 3.0 days. The deviation from Research Forum Abstracts S38 Annals of Emergency Medicine Volume 46, no. 3 : September 2005
Transcript of Utility of the ED Pelvic Exam: Results of a Prospective Pilot Study
ED patients presenting with NSAP. Subjects underwent prompted history andphysical examination including rectal examination and stool occult blood testing,a standard battery of laboratory studies, acute abdominal series radiographs andnon-contrast helical computed tomography. Subjects were followed up to sixmonths for ultimate diagnosis and outcome.
Statistical analysis: Standard contingency table and chi-square analysis wereperformed in order to determine sensitivity, specificity, positive and negativelikelihood ratios, and significance of positive and negative findings in predictingUI diagnosis.
Results: Results of stool gross- and occult-blood examination obtained from rectalexamination were available for 152 subjects. Colorimetric quality control analysis wasperformed on all occult blood tests - all were positive. Of the subject samples, one waspositive for gross blood, and had a final diagnosis of diverticulitis requiring hospitaladmission (coded UIC). Of the remaining 151 subjects, 15 were positive for occultblood, of which 9 required UI (true positive rate 60%). Ultimate diagnoses includedadenocarcinoma of the colon (2), appendicitis (2), diverticulitis, ulcerative colitis, smallbowel obstruction, ileus and obstructive pancreatitis. Of the 136 occult-negativesubjects, 55 required UI (false negative rate 40%). Contingency table analysis of stooloccult blood as a predictor of UI yielded the following: sensitivity .14, specificity .93,LRC2.04, LR- .92. Chi-square analysis yielded a result of 1.48, with 2 degrees offreedom, yielding a p\ 0.48 (insignificant).
Conclusion: The presence of gross- or occult-blood in the tool samples of NSAPpatients tended to be weakly predictive of the need for UI. A negative result was of nodiagnostic value. Given that stool samples for analysis may be obtained easily bydigital rectal examination, rectal thermometer probe or swab, continuation of thispractice as a rapid bedside screen for potentially life-threatening conditions in patientspresenting with NSAP appears to be indicated.
131 Influence of Sex on the Management of Appendicitis
Crystal CS, Howland TR, Skinner CG, Miller MA, Coon TP, Darnall Army Community
Hospital, Fort Hood, TX
Study Objectives: The influence of sex on the management of appendicitis hasbeen well hypothesized. We sought to evaluate the management of appendicitis in amilitary community hospital with a predominantly male population and determinethe influence of sex on the ordering of CT, CT test characteristics, negativelaparotomy rate, and perforation rate.
Methods: A retrospectrive chart review was performed on all charts with a finaldiagnosis of appendicitis or perforated appendicitis at an academic militarycommunity emergency department (60,000 visits per year) between January 1 andDecember 31, 2004. The hospital’s computerized tracking system was used toidentify final diagnoses. Appendectomy patients never seen in the ED, and patientsthat had a normal appendix removed during other surgical exploration were excludedfrom the study. Medical records were reviewed by two physicians each blinded to thepatient’s final diagnosis. Data regarding age, sex, whether a CT was performed or not,and radiologist interpretation (negative, positive, or indeterminant) was recorded on astandard data collection form. Pathology results were then reviewed and recorded asappendicitis, perforated appendicitis, or normal appendix. Percentages werecalculated for the total patient population, males, and females for the ordering of CT,negative laporatomy rate, and perforation rate. The sensitivity of CT was alsocalculated by sex.
Results: 109 appendectomies for suspected appendicitis were performed duringthe study period with 90 patients having pathology confirmed appendicitis. Therewere 69 male and 40 female patients total. Eighty patients had a CT ordered and sexdid not influence ordering (71% male vs. 77.5% female; p=0.460). CT had an overallsensitivity of 88.4% (90.5% male and 85.2% for female). The total rate of negativelaparotomies was 17.4% with no difference between males and females (18.8% vs.15%; p=0.610). When comparing negative lap rates for patients receiving CT or notthere was no difference for females or total patients; however, male patients notreceiving CT had a significantly higher negative laparotomy rate when compared tomales receiving a CT (30.0% vs. 14.3%; p=0.027). 17 patients (15.6%) in our studyhad a perforated appendix, 11 male and 6 female (p=0.896) (see Table).
Conclusion: Sex had no influence on the ordering of CT, negative laparotomyrate, or perforation rate at our predominately male population community hospital.CT sensitivity was similar between males and females and the ordering of CT did notalter the overall negative lap rate. However, the negative lap rate was significantlyhigher in males not receiving a CT when compared to males receiving a CT.
132 ED Presentation of Dyspnea in HF Patients Results
in Increased Hospital Stay and Medication Costs
Milzman DP, Ennis J, Barbaccia J, Davis G, Gebreyes K, Madan S, Washington
Hospital Center, Washington, DC
Objectives: Correctly identifying Decompensated Heart Failure (DHF) as thecause of dyspnea during ED presentation has been assumed to be fairly routine. ThisStudy will evaluate initial treatments of attending EPs on confirmed HF patientswithout any markers to aid proper diagnoses such as BNP.
Methods: Consecutive patients presenting to an urban teaching ED werereviewed at discharge for a primary diagnoses of Heart Failure: ‘DRG 127’. The studyincluded all DHF patients admitted directly through the ED Patients receivingantibiotics during the ED care period were compared to all other DHF patientsbased on outcomes and costs at hospital discharge.
Results: There were a total of 2,413 patients presenting directly to the ED andreceiving a primary discharge diagnoses of HF (DRG 127). Further analysis for anyinfectious causation and need for antibiotic treatment based on chart review anddischarge diagnosis reduced the total number of patients to 1,946. 1,461 did notreceive antibiotic(AB) and 485 DHF patients received extended spectrum AB in theED based on preliminary diagnosis attributed to either pneumonia or bronchitisbased on complaints and initial CXR read by EP. 78% of DHF patients had SOBand/or CP as triage chief complaint, none had fever and \5% had coughing or legswelling. The total hospital days for the antibiotic treatment group were 5.2 dayscompared to the DHF group without initial AB of 3.0 days. The deviation from
Research Forum Abstracts
130 Utility of the ED Pelvic Exam: Results of a
Prospective Pilot Study
Brown J, Aristizabal J, Nicoll K, The George Washington University, Washington,
DC; The George Washington University School of Medicine, Washington, DC
Study Objectives: Most standard emergency medicine texts emphasize theimportance of performing a pelvic exam on any female patient with abdominal painor vaginal bleeding. The utility of this exam has never been prospectively evaluated,despite the fact that this exam may be physically and emotionally painful for thefemale patient. We sought to determine the utility of performing the exam in thispopulation of emergency department patients.
Methods: In a large academic emergency department, female patientsundergoing a pelvic exam and the physicians caring for them were approached bytrained research assistants. Research assistants enrolled consecutive patients 16 hours aday over a three month period. After informed consent from both patient andprovider, demographics were collected as well as the results of the general physicalexam. Prior to performing the pelvic exam, the health care provider was asked topredict the results. The actual findings of the exam were compared with the predictedfindings. Results of laboratory and radiographic tests were also correlated with thepredicted and actual findings of the pelvic exam.
Results: Ninety-one patients were prospectively entered into the study. The meanage was 30 with a range of 18-55 years. The most common presenting symptomswere abdominal pain (n=65, 71%), vaginal bleeding (n= 41, 45%), side pain (n=21,23%), nausea (n=21, 23%), and vaginal bleeding (n=14, 15%). Twelve patients(13%) were pregnant. The exam was performed 16% of the time by medical students(n=14), 14% of the time by interns (n=12), and 69% of the time by residents (n=63).Thirty-six (39%) of the examining physicians were EM residents. The most commonreasons for performing the pelvic exam were: to assess for adnexal tenderness (n=44,48%), to assess the os and check for ongoing uterine bleeding (n=38, 42%), toevaluate for cervical motion tenderness (n=36, 39%), to look for a discharge (n=31,34%) or products of conception (n=18, 20%), or to evaluate for uterine tenderness(n=25, 27%). When compared with predicted findings, the pelvic exam was asexpected in 62 patients (68%). In a further 25 patients (27%), the findings of thepelvic exam were not as predicted, but resulted in no change in the clinical plan. Inonly 4 cases (4%), did the exam reveal a finding that was both unexpected andchanged the clinical plan. One of these four patients was admitted. Review of this caseshowed the patient was admitted for a urinary tract infection, and not because of anyfindings on physical exam. Of the 4 patients who were admitted (4%), two patientshad a pelvic exam that revealed unexpected results, and only one of these caused thephysician to change the care planned for the patient.
Conclusion: In over 95% of patients, the results of the pelvic exam werepredictable. Further research should be conducted to determine the predictive factorsthat may allow a pelvic exam to be safely deferred.
S38 Annals of Emergency Medicine Volume 46, no. 3 : September 2005
