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Although cases of Vitamin D-deficient Rickets have declined since the Industrial Revolution, certain populations remain at risk. Risk factors for developing vitamin D-deficient Rickets include breast-feeding without formula or vitamin supplementation, very dark skin and inadequate exposure to sunlight. We describe a case of Rickets in a breastfed infant with dark skin who presented with hypocalcemic seizures. The pathophysiology of Rickets is briefly described along with the emergency management of infants presenting with hypocalcemic seizure.

We report a case of small bowel obstruction secondary to coin ingestion. A 22-year-old woman presented to the Emergency Department (ED) with a 3-week history of abdominal pain. Upon initial history the patient denied any foreign body ingestion. Only after computed tomography (CT) scanning of the abdomen and pelvis did the patient admit to deliberate ingestion of a single United States penny coin. During surgical evaluation it was found that the coin had lodged near the ileocecal valve and an inflammatory mass had formed around the intraluminal coin, causing a 10 x 7 cm fibrous tumor to completely obstruct the small bowel. It is thought that oxidation of the coin, with subsequent exposure of its high zinc content, instigated the inflammatory cascade.

Study objective: The emergency department is a problem-focused environment in which routine screening for intimate partner violence (IPV) is difficult. We hypothesized that screening for IPV during computer-based health-risk assessment would be acceptable to patients and improve detection. Methods: We performed a descriptive study of IPV data collected during a controlled trial of computer-based health promotion in an urban hospital ED. Patients received computer-generated health advice, and physicians received patient risk summaries. Outcomes were patient disclosure and physician documentation of IPV and associated risks. Results: Two hundred forty-eight patients (69% female, 90% black, mean age 39 years) participated in a clinical trial of computer-based health promotion in the ED. Of 170 women, 53 (33%) disclosed emotional abuse, and 25 (15%) disclosed physical abuse. Of 78 men, 22 (29%) disclosed emotional abuse, and 5 (6%) disclosed physical abuse. Patients were also willing to self-report a history or concern of hurting someone close to them. This was true for 21 (14%) women and 15 (22%) men. Controlling for demographic factors, disclosures of victimization and perpetration were associated with multiple psychosocial risks. Computer screening resulted in chart documentation in 19 of 83 potential cases of IPV compared with 1 case documented in the group that received usual care. Conclusion: Providing an opportunity for patients to confidentially self-disclose IPV has the potential to supplement current screening efforts and to allow providers to focus on assessment, counseling, and referral for those at risk. However, further measures will be needed to ensure that information gathered through computer screening is adequately addressed during the acute care or follow-up visit. [ Ann Emerg Med. 2002;40:476-484.]

Extensive laboratory testing is often performed in the emergency department evaluation of the new-onset seizure patient. To determine the utility of such testing, a prospective study of patients with a new-onset seizure presenting to the ED of an inner-city, university-affiliated teaching hospital was done. One hundred thirty-six patients were entered into the study between October 1984 and January 1988. All patients had uniform data collection performed. Pertinent historical information and physical examination findings were recorded on a standardized form before laboratory abnormality was a sole or contributory cause of the seizure disorder. These included four patients with hypoglycemia, four with hyperglycemia, two with hypocalcemia, and one with hypomagnesemia. Only two cases (hypoglycemia) were not suspected on the basis of findings on the history or physical examination. In ED patients, the incidence of a new-onset seizure due to a correctable metabolic disturbance is low. We conclude that, with the exception of the serum glucose, the extensive ED laboratory workup often done for the evaluation of a new-onset seizure is unnecessary. Further test ordering should be directed by the medical history and physical examination.

The patient with a red eye constitutes a very common clinical problem encountered in the Emergency Department setting. Conjunctivitis, the most common cause of the red eye, generally is not associated with disturbance of vision or associated ocular pain. If either of these symptoms is present, a more serious disorder must be suspected. Treatment of infectious conjunctivitis is guided by interpretation of a Gram's stain and subsequent culture of any exudate present. Initial treatment of most cases includes use of topical antibiotic and local comfort measures. Complications of infectious conjunctivitis include more invasive disease such as keratitis or abscess formation, with potential corneal perforation and destruction. All patients should be referred for ophthalmologic followup, both to assess adequacy of treatment and to treat unexpected complications. Remember that allergic conjunctivitis is a common condition that responds to antihistamine decongestant medications given orally or topically. Occasionally these conditions are caused by self-prescribed use of ocular medication, and discontinuation of all eye medication is required. Corticosteroid eye drops are rarely indicated and should be used only at the direction of an ophthalmologist. When the diagnosis is uncertain, treatment is best withheld, as "shotgun" therapy is seldom beneficial.

Women experiencing domestic violence (DV) frequent health care settings, but DV is rarely identified.We conducted a randomized controlled trial to determine the effect of computer screening on health care provider-patient DV communication at 2 socioeconomically diverse emergency departments (EDs). Consenting nonemergent female patients, aged 18 to 65 years, were randomized to self-administered computer-based health risk assessment, with a prompt for the health care provider, or to "usual care"; all visits were audiotaped. Outcome measures were rates of DV discussion, disclosure, and services.Of 2169 eligible patients, 1281 (59%) consented; 871 (68%) were successfully audiotaped, and 903 (71%) completed an exit questionnaire. Rates of current DV risk on exit questionnaire were 26% in the urban ED and 21% in the suburban ED. In the urban ED, the computer prompt increased rates of DV discussion (147/262 [56%] vs 123/275 [45%]; P = .004), disclosure (37/262 [14%] vs 23/275 [8%]; P = .07), and services provided (21 [8%] vs 10 [4%]; P = .04). Women at the suburban site and those with private insurance or higher education were much less likely to be asked about experiences with abuse. Only 48% of encounters with a health care provider prompt regarding potential DV risk led to discussions. Both inquiries about and disclosures of abuse were associated with higher patient satisfaction with care.Computer screening for DV increased but did not guarantee that DV would be addressed during ED encounters. Nonetheless, it is likely that low-cost interventions that allow patients the opportunity to self-disclose can be used to improve detection of DV.

Background Previous trials have showed a 10–30% rate of inaccuracies on applications to individual residency programs. No studies have attempted to corroborate this on a national level. Attempts by residency programs to diminish the frequency of inaccuracies on applications have not been reported. We seek to clarify the national incidence of inaccuracies on applications to emergency medicine residency programs. Methods This is a multi-center, single-blinded, randomized, cohort study of all applicants from LCME accredited schools to involved EM residency programs. Applications were randomly selected to investigate claims of AOA election, advanced degrees and publications. Errors were reported to applicants' deans and the NRMP. Results Nine residencies reviewed 493 applications (28.6% of all applicants who applied to any EM program). 56 applications (11.4%, 95%CI 8.6–14.2%) contained at least one error. Excluding "benign" errors, 9.8% (95% CI 7.2–12.4%), contained at least one error. 41% (95% CI 35.0–47.0%) of all publications contained an error. All AOA membership claims were verified, but 13.7% (95%CI 4.4–23.1%) of claimed advanced degrees were inaccurate. Inter-rater reliability of evaluations was good. Investigators were reluctant to notify applicants' dean's offices and the NRMP. Conclusion This is the largest study to date of accuracy on application for residency and the first such multi-centered trial. High rates of incorrect data were found on applications. This data will serve as a baseline for future years of the project, with emphasis on reporting inaccuracies and warning applicants of the project's goals.

Study objective We characterize communication in an urban, academic medical center emergency department (ED) with regard to the timing and nature of the medical history survey and physical examination and discharge instructions. Methods Audiotaping and coding of 93 ED encounters (62 medical history surveys and physical examinations, 31 discharges) with a convenience sample of 24 emergency medicine residents, 8 nurses, and 93 nonemergency adult patients. Results Patients were 68% women and 84% black, with a mean age of 45 years. Emergency medicine providers were 70% men and 80% white. Of 62 medical history surveys and physical examinations, time spent on the introduction and medical history survey and physical examination averaged 7 minutes 31 seconds (range 1 to 20 minutes). Emergency medicine residents introduced themselves in only two thirds of encounters, rarely (8%) indicating their training status. Despite physician tendency (63%) to start with an open-ended question, only 20% of patients completed their presenting complaint without interruption. Average time to interruption (usually a closed question) was 12 seconds. Discharge instructions averaged 76 seconds (range 7 to 202 seconds). Information on diagnosis, expected course of illness, self-care, use of medications, time-specified follow-up, and symptoms that should prompt return to the ED were each discussed less than 65% of the time. Only 16% of patients were asked whether they had questions, and there were no instances in which the provider confirmed patient understanding of the information. Conclusion Academic EDs present unique challenges to effective communication. In our study, the physician-patient encounter was brief and lacking in important health information. Provision of patient-centered care in academic EDs will require more provider education and significant system support.

To introduce and assess the time savings from and effectiveness of assessment-oriented (AO) oral case presentation as a model of interphysician communication.This was a prospective, interventional study of all 10 on-site faculty and 36 residents in a postgraduate year 1 to 3 format emergency medicine residency training program. Residents were requested to perform all oral case presentations in either the traditional or AO formats. Presentations were timed, and residents and faculty rated essential measures of oral case presentation effectiveness: data content, expression of decision making, organization, and overall satisfaction.A total of 199 oral case presentations were sampled-112 traditional and 87 AO. Mean length of presentation for traditional presentations was 117 seconds versus 71 seconds for AO presentations (p0.001), a clinically significant difference, without significant differences in the essential measures of case presentation effectiveness.AO oral case presentation may provide a means for emergency medicine residents to "get to the point" and to communicate effectively and efficiently.

Clostridial myonecrosis (CM) is a rare, life-threatening infection that is most often associated with recent surgery or skeletal muscle trauma. It usually affects patients with some degree of underlying immunocompromise or vascular insufficiency. Occasionally, CM can occur at remote sites, with seeding from a gastrointestinal source in the setting of malignancy. We report a case of a 75-year-old man who developed rapidly progressive myonecrosis in the right shoulder, without prior trauma, caused by Clostridium septicum. On autopsy, this patient was found to have previously undiagnosed radiation colitis with ulcerations and abscess formation, secondary to recent prostate cancer radiation therapy. Although several case reports discuss CM in the setting of bowel malignancy, our case illustrates that non-malignant bowel inflammation may be a sufficient source for the infection. Clinical features of this uncommon disease are discussed, and the relevant literature is reviewed with regard to Clostridium septicum as an etiologic agent.

Acquired hemophilia is a rare disorder that has potentially disastrous consequences if not recognized and treated in the setting of acute hemorrhage. We report a case of undiagnosed acquired hemophilia due to factor VIII inhibitor in which a tongue hematoma was the chief manifestation. Diagnosis, acute management, and long-term therapeutic options are reviewed.

Study Objective: We evaluate a computer-based intervention for screening and health promotion in the emergency department and determine its effect on patient recall of health advice. Methods: This controlled clinical trial, with alternating assignment of patients to a computer intervention (prevention group) or usual care, was conducted in a university hospital ED. The study group consisted of 542 adult patients with nonurgent conditions. The study intervention was a self-administered computer survey generating individualized health information. Outcome measures were (1) patient willingness to take a computerized health risk assessment, (2) disclosure of behavioral risk factors, (3) requests for health information, and (4) remembered health advice. Results: Eighty-nine percent (470/542) of eligible patients participated. Ninety percent were black. Eighty-five percent (210/248) of patients in the prevention group disclosed 1 or more major behavioral risk factors including current smoking (79/248; 32%), untreated hypertension (28/248; 13%), problem drinking (46/248; 19%), use of street drugs (33/248; 13%), major depression (87/248; 35%), unsafe sexual behavior (84/248; 33%), and several other injury-prone behaviors. Ninety-five percent of patients in the prevention group requested health information. On follow-up at 1 week, 62% (133/216) of the prevention group patients compared with 27% (48/180) of the control subjects remembered receiving advice on what they could do to improve their health (relative risk 2.3, 95% confidence interval 1.77 to 3.01). Conclusion: Using a self-administered computer-based health risk assessment, the majority of patients in our urban ED disclosed important health risks and requested information. They were more likely than a control group to remember receiving advice on what they could do to improve their health. Computer methodology may enable physicians to use patient waiting time for health promotion and to target at-risk patients for specific interventions. [Rhodes KV, Lauderdale DS, Stocking CB, Howes DS, Roizen MF, Levinson W. Better health while you wait: a controlled trial of a computer-based intervention for screening and health promotion in the emergency department. Ann Emerg Med. March 2001;37:284-291.]

Essentially, emergency medicine encompasses the efficient application of limited resources to provide timely care to patients in health crisis. The appropriate triage, management, and disposition of patients with orofacial complaints requires systematic evaluation with attention to the ABCs. The first priority is to secure the airway. Once such a patient has been stabilized, a thorough examination, with documentation of the oropharyngeal and facial examination, should be conducted. Unfortunately, many conditions seen initially in the ED through patient self-referral ultimately require specialist care. Therefore, emergency physicians must temporarily provide pain relief and begin initial treatment of traumatic, infectious, or inflammatory conditions that await more definitive intervention. The emergency physician should consider it his or her role to exclude life threats, prevent complications, provide patient comfort, and ensure adequate and timely follow-up care.

The Ehlers-Danlos syndrome (EDS) is a group of hereditary connective tissue disorders that are characterized by abnormalities of the skin, joints, and a diversity of other phenotypic manifestations. An awareness of the disease is vital for optimal outcome in this rare group of patients who may present with a variety of life-threatening illnesses. Ehlers-Danlos type IV has been associated with vascular catastrophes, perforated viscous, ruptured uterus, and pneumothorax (1-4). We present a case of aneurysmal formation and spontaneous rupture of the great vessels in a 15-year-old male with EDS type IV, who remained undiagnosed until the time of autopsy.

The patient with a red eye constitutes a very common clinical problem encountered in the Emergency Department setting. Conjunctivitis, the most common cause of the red eye, generally is not associated with disturbance of vision or associated ocular pain. If either of these symptoms is present, a more serious disorder must be suspected. Treatment of infectious conjunctivitis is guided by interpretation of a Gram's stain and subsequent culture of any exudate present. Initial treatment of most cases includes use of topical antibiotic and local comfort measures. Complications of infectious conjunctivitis include more invasive disease such as keratitis or abscess formation, with potential corneal perforation and destruction. All patients should be referred for ophthalmologic followup, both to assess adequacy of treatment and to treat unexpected complications. Remember that allergic conjunctivitis is a common condition that responds to antihistamine decongestant medications given orally or topically. Occasionally these conditions are caused by self-prescribed use of ocular medication, and discontinuation of all eye medication is required. Corticosteroid eye drops are rarely indicated and should be used only at the direction of an ophthalmologist. When the diagnosis is uncertain, treatment is best withheld, as "shotgun" therapy is seldom beneficial.

The mental status evaluation is a useful test in the emergency department. The major purposes of the examination are to determine the presence of neuropsychiatric illness and to determine whether this illness is functional or organic. The most accepted evaluation of mental status is the formal mental status evaluation. This extensive test is rarely necessary in the emergency department; rather a short test of cognitive function, such as the Cognitive Capacity Screening Examination or Mini-Mental Status Examination, may be more appropriate. With frequent repetition in use and the concomitant development of clear standards for interpretation of the examination used, the emergency physician will become more comfortable with bedside mental status testing.

In many institutions it is the "standard of care" to obtain serum chemistries and anticonvulsant levels as part of the emergency department evaluation of seizure patients. To determine the efficacy of such a workup in the ED, 163 seizure patients presenting to an inner-city teaching hospital were studied in a standardized, prospective manner. After the clinical examination all patients had CBC, serum electrolyte, BUN, creatinine, glucose, calcium, magnesium, and if indicated, anticonvulsant drug level determinations performed. Any patient presenting with a first-time seizure (in patients greater than 6 years old), recent head trauma, focal neurologic deficit, or focal seizure activity had cranial computerized tomography (CCT). After obtaining historical and physical examination and before receiving laboratory results, as many as five likely etiologies were listed and assigned probability ratings. After review of the laboratory data (and CCT scan, if obtained), final etiologies again were listed and assigned percentages of likelihood. Significant abnormalities (ie, those that changed diagnosis, management, or disposition) were found in 104 patients; 96 had subtherapeutic anticonvulsant levels, five had abnormal CCT scans, two had hypoglycemia, and one had hyperglycemia as the cause of seizure. The clinical examination successfully predicted those abnormalities in all but two cases (one each of hyperglycemia and subdural hematoma). We contend tha routine serum chemistries in patients presenting to the ED are of extremely low yield, and that the clinical examination can predict accurately the need to obtain these studies. CCT scanning is useful in selected patients, and was found to be abnormal in five of 19 (25%) patients.(ABSTRACT TRUNCATED AT 250 WORDS)