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Physician gestalt

Hendry Robert Sawe, Cathryn Haeffele, Juma A Mfinanga, Victor G Mwafongo, Teri A Reynolds
BACKGROUND: Bedside inferior vena cava (IVC) ultrasound has been proposed as a non-invasive measure of volume status. We compared ultrasound measurements of the caval index (CI) and physician gestalt to predict blood pressure response in patients requiring intravenous fluid resuscitation. METHODS: This was a prospective study of adult emergency department patients requiring fluid resuscitation. A structured data sheet was used to record serial vital signs and the treating clinician's impression of patient volume status and cause of hypotension...
2016: PloS One
Brit Long, Alex Koyfman
BACKGROUND: Bacteremia affects 200,000 patients per year, with the potential for significant morbidity and mortality. Blood cultures are considered the most sensitive method for detecting bacteremia and are commonly obtained in patients with fever, chills, leukocytosis, focal infections, and sepsis. OBJECTIVE: We sought to provide emergency physicians with a review of the literature concerning blood cultures in the emergency department. DISCUSSION: The utility of blood cultures has been a focus of controversy, prompting research evaluating effects on patient management...
September 14, 2016: Journal of Emergency Medicine
Jeffrey A Kline, Dawn Neumann, Cassandra L Hall, Jacob Capito
BACKGROUND: Many clinicians use a global visual interpretation of patient appearance to decide if a patient looks sick or not. For patients with suspected acute pulmonary embolism (PE), we tested the relationship between visual appearance of a happy patient facial affect and probability of PE+ on CT pulmonary angiography (CTPA). METHODS: Eligible patients were selected by usual care to undergo CTPA, the criterion standard for PE+ or PE-. Prior to CTPA result, trained study personnel obtained physician pretest probability using the gestalt method (visual analogue scale, 0%-100%), the Wells score (0-12) and physicians' impression of whether the patient smiled during the initial examination (smile+)...
August 2, 2016: Emergency Medicine Journal: EMJ
Zachary M Grinspan, Yonina C Eldar, Daniel Gopher, Amihai Gottlieb, Rotem Lammfromm, Halinder S Mangat, Nimrod Peleg, Steven Pon, Igal Rozenberg, Nicholas D Schiff, David E Stark, Peter Yan, Hillel Pratt, Barry E Kosofsky
BACKGROUND: Physicians caring for children with serious acute neurologic disease must process overwhelming amounts of physiological and medical information. Strategies to optimize real time display of this information are understudied. OBJECTIVES: Our goal was to engage clinical and engineering experts to develop guiding principles for creating a pediatric neurology intensive care unit (neuroPICU) monitor that integrates and displays data from multiple sources in an intuitive and informative manner...
2016: Applied Clinical Informatics
Gianfranco Cervellin, Gianni Rastelli
Risk stratification and management of patients with chest pain continues to be challenging despite considerable efforts made in the last decades by many clinicians and researchers. The throutful evaluation necessitates that the physicians have a high index of suspicion for acute coronary syndrome (ACS) and always keep in mind the myriad of often subtle and atypical presentations of ischemic heart disease, especially in certain patient populations such as the elderly ones. In this article we aim to review and discuss the available evidence on the value of clinical presentation in patients with a suspected ACS, with special emphasis on history, characteristics of chest pain, associated symptoms, atypical presentations, precipitating and relieving factors, drugs, clinical rules and significance of clinical Gestalt...
May 2016: Annals of Translational Medicine
Janneke M T Hendriksen, Wim A M Lucassen, Petra M G Erkens, Henri E J H Stoffers, Henk C P M van Weert, Harry R Büller, Arno W Hoes, Karel G M Moons, Geert-Jan Geersing
PURPOSE: Diagnostic prediction models such as the Wells rule can be used for safely ruling out pulmonary embolism (PE) when it is suspected. A physician's own probability estimate ("gestalt"), however, is commonly used instead. We evaluated the diagnostic performance of both approaches in primary care. METHODS: Family physicians estimated the probability of PE on a scale of 0% to 100% (gestalt) and calculated the Wells rule score in 598 patients with suspected PE who were thereafter referred to secondary care for definitive testing...
May 2016: Annals of Family Medicine
Adam C Pomerleau, Justin D Schrager, Brent W Morgan
INTRODUCTION: Little is known about the factors driving decision-making among emergency department (ED) providers when prescribing opioid analgesics (OA). The aim of this pilot study was to identify the importance of factors influencing OA-prescribing decisions and to determine how this varied among different types of providers. METHODS: This was an observational cross-sectional survey study of 203 ED providers. The importance of decisional factors was rated on a 5-point Likert scale...
September 2016: Journal of Medical Toxicology: Official Journal of the American College of Medical Toxicology
Sean K Golden, John B Harringa, Perry J Pickhardt, Alexander Ebinger, James E Svenson, Ying-Qi Zhao, Zhanhai Li, Ryan P Westergaard, William J Ehlenbach, Michael D Repplinger
OBJECTIVE: To determine whether clinical scoring systems or physician gestalt can obviate the need for computed tomography (CT) in patients with possible appendicitis. METHODS: Prospective, observational study of patients with abdominal pain at an academic emergency department (ED) from February 2012 to February 2014. Patients over 11 years old who had a CT ordered for possible appendicitis were eligible. All parameters needed to calculate the scores were recorded on standardised forms prior to CT...
July 2016: Emergency Medicine Journal: EMJ
Hendry Robert Sawe, Juma A Mfinanga, Victor Mwafongo, Teri A Reynolds, Michael S Runyon
OBJECTIVES: To evaluate the test characteristics of clinical gestalt for detecting the presence and severity of anaemia in emergency department patients at a tertiary referral hospital in Tanzania. METHODS: This prospective study enrolled a convenience sample of emergency department patients who had a complete blood count ordered by the treating physician in the course of their clinical care. Physicians recorded their impression of the presence and severity of anaemia before viewing the laboratory results...
May 2016: Emergency Medicine Journal: EMJ
Yonathan Freund, Alexandra Rousseau, France Guyot-Rousseau, Yann-Erick Claessens, Olivier Hugli, Olivier Sanchez, Tabassome Simon, Bruno Riou
BACKGROUND: The diagnosis of Pulmonary Embolism (PE) in the emergency department (ED) is crucial. As emergency physicians fear missing this potential life-threatening condition, PE tends to be over-investigated, exposing patients to unnecessary risks and uncertain benefit in terms of outcome. The Pulmonary Embolism Rule-out Criteria (PERC) is an eight-item block of clinical criteria that can identify patients who can safely be discharged from the ED without further investigation for PE...
2015: Trials
Ralph C Wang, Robert M Rodriguez, Michelle Moghadassi, Vicki Noble, John Bailitz, Mike Mallin, Jill Corbo, Tarina L Kang, Phillip Chu, Steve Shiboski, Rebecca Smith-Bindman
STUDY OBJECTIVE: The STONE score is a clinical decision rule that classifies patients with suspected nephrolithiasis into low-, moderate-, and high-score groups, with corresponding probabilities of ureteral stone. We evaluate the STONE score in a multi-institutional cohort compared with physician gestalt and hypothesize that it has a sufficiently high specificity to allow clinicians to defer computed tomography (CT) scan in patients with suspected nephrolithiasis. METHODS: We assessed the STONE score with data from a randomized trial for participants with suspected nephrolithiasis who enrolled at 9 emergency departments between October 2011 and February 2013...
April 2016: Annals of Emergency Medicine
Michael Mouw, Tatiana Balatiouk-Lance, Lawrence H Brown
No abstract text is available yet for this article.
November 2015: American Journal of Emergency Medicine
Arash Mokhtari, Eric Dryver, Martin Söderholm, Ulf Ekelund
In the assessment of chest pain patients with suspected acute coronary syndrome (ACS) in the emergency department (ED), physicians rely on global diagnostic impressions ('gestalt'). The aim of this study was to determine the diagnostic value of the ED physician's overall assessment of ACS likelihood, and the values of the main diagnostic modalities underlying this assessment, namely the chest pain history, the ECG and the initial troponin result. 1,151 consecutive ED chest pain patients were prospectively included...
2015: SpringerPlus
Marc A Probst, Hemal K Kanzaria, Jerome R Hoffman, William R Mower, Roya S Moheimani, Benjamin C Sun, Denise D Quigley
BACKGROUND: Palpitations are a common emergency department (ED) complaint, yet relatively little research exists on this topic from an emergency care perspective. OBJECTIVES: We sought to describe the perceptions and clinical decision-making processes of emergency physicians (EP) surrounding patients with palpitations. METHODS: We conducted 21 semistructured interviews with a convenience sample of EPs. We recruited participants from academic and community practice settings from four regions of the United States...
August 2015: Journal of Emergency Medicine
Jeffrey A Kline, Christopher Kabrhel
BACKGROUND: In part 1 of this two-part review, we discussed which risk factors, historical features, and physical findings increase risk for pulmonary embolism (PE) in symptomatic emergency department (ED) patients. OBJECTIVES: Use published evidence to describe criteria that a reasonable and prudent clinician can use to initiate and guide the process of excluding and diagnosing PE. DISCUSSION: The careful and diligent emergency physician can use clinical criteria to safely obviate a formal evaluation of PE, including the use of gestalt reasoning and the pulmonary embolism rule-out criteria (PERC rule, Table 2, part 1)...
July 2015: Journal of Emergency Medicine
Robert J Smith, Austin S Kilaru, Jeanmarie Perrone, Breah Paciotti, Frances K Barg, Sarah M Gadsden, Zachary F Meisel
OBJECTIVE: The prescription opioid epidemic is currently responsible for the greatest number of unintentional deaths in the United States. One potential strategy for decreasing this epidemic is implementation of state-based Prescription Drug Monitoring Programs (PDMPs), which are designed for providers to identify patients who "doctor shop" for prescriptions. Emergency medicine physicians are some of the most frequent PDMP users and opioid prescribers, but little is known about how they actually use PDMPs, for which patients, and for what reasons...
June 2015: Pain Medicine: the Official Journal of the American Academy of Pain Medicine
Frances M Russell, Robert R Ehrman, Karen Cosby, Asim Ansari, Stephanie Tseeng, Errick Christain, John Bailitz
OBJECTIVES: The primary goal of this study was to determine accuracy for diagnosing acutely decompensated heart failure (ADHF) in the undifferentiated dyspneic emergency department (ED) patient using a lung and cardiac ultrasound (LuCUS) protocol. Secondary objectives were to determine if US findings acutely change management and if findings are more accurate than clinical gestalt. METHODS: This was a prospective, observational study of adult patients presenting to the ED with undifferentiated dyspnea...
February 2015: Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine
Aymen N Naguib, Peter D Winch, Joseph D Tobias, Janet Simsic, Diane Hersey, Kathleen Nicol, Thomas Preston, Daniel Gomez, Patrick McConnell, Mark Galantowicz
BACKGROUND: The transfusion of blood products in the setting of uncontrolled bleeding is unquestionably lifesaving. However, in many instances, the decision to transfuse is based on physician gestalt rather than medical evidence. When indications for transfusion are unclear, the benefits of blood products must be balanced against their significant risks and associated costs. As our institution is a referral center for patients of Jehovah's Witness faith, this population has pushed our development of techniques to achieve the goal of bloodless surgery...
May 2015: Paediatric Anaesthesia
Joshua Jauregui, Daniel Nelson, Esther Choo, Branden Stearns, Adam C Levine, Otto Liebmann, Sachita P Shah
BACKGROUND: Prior research suggests that the ratio of the ultrasound-measured diameter of the inferior vena cava to the aorta correlates with the level of dehydration in children. This study was designed to externally validate this and to access the accuracy of the ultrasound measured inspiratory IVC collapse and physician gestalt to predict significant dehydration in children in the emergency department. METHODS: We prospectively enrolled a non-consecutive cohort of children ≤18 years old...
2014: Critical Ultrasound Journal
Anniek Visser, Albert Wolthuis, Rob Breedveld, Ewoud ter Avest
BACKGROUND: Acute coronary syndrome (ACS) can be a diagnostic challenge in the emergency department (ED). Recently, the HEART score was developed, a simple bedside scoring system that quantifies risk of ischaemic events in patients with undifferentiated chest pain presenting in the ED. OBJECTIVE: In this prospective cohort study, we compared the diagnostic accuracy of HEART score and clinical gestalt (clinical judgement) for diagnosing ACS in an unselected population of patients with chest pain presenting to the ED...
August 2015: Emergency Medicine Journal: EMJ
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