This RMD Review comes from patient feedback regarding transferring care to the emergency room. Many of our patients feel the provider who sent them to the ER did not listen to them, evaluate them, or care about them as people or patients.
When it comes to CRH Healthcare clinics, there are two distinct categories of patients who need emergency evaluation.
The first category is the patient who simply needs more testing to definitively rule in or rule out an emergent condition. This patient’s risk is typically lower, but it is not negligible. The condition must be further evaluated due to the medical risk to the patient. The second category is the patient who is in an obvious emergency, such as a crushing substernal chest pain or facial drooping.
This article mainly pertains to the first category of patients. The second category of patients should receive expedited triage by calling EMS while the provider evaluates the patient’s safety and stability.
As healthcare providers, we understand that certain conditions cannot be fully treated in an urgent care facility. We know that a 70-year-old with a head injury needs a head CT; however, our patients often do not share this same level of knowledge or understanding. One of our responsibilities is to educate these patients so they understand the necessity of emergency workup and treatment.
The first point of this approach is to treat the patient as you would any other. Follow the AIDET guidelines. Take a complete history. Perform a complete physical examination. Perform any point-of-care testing. Then, present the treatment plan to the patient. This treatment plan may include a referral to an ER.
When you have a complete assessment, patients are more likely to feel heard and adequately cared for, which helps establish strong medical reasoning for ER referral.
A 42-year-old female with a past medical history of GERD and obesity presented to the clinic on Saturday at 8 a.m.
The patient reported abdominal pain that had been intermittent for two to three months. The pain previously lasted a few hours at a time. Now, the pain has become persistent for the past three to four days. Vital signs are within normal limits and stable.
The patient’s exam reveals tenderness to palpation of the epigastric and right upper quadrants. Murphy sign is further positive. Due to a complaint of abdominal pain in a woman of childbearing years, a UA and UPT were completed as a standing order. Both were negative.
The treatment plan was presented to the patient with an ER recommendation for a presumed diagnosis of gallbladder irritation, which was likely caused by a gallstone that had been popping in and out of the exit of the gallbladder for the past months causing the patient pain but was now likely stuck causing the buildup and irritation in the gallbladder.
It was further explained to the patient that the process of the condition could lead to infection and even death or that a gallstone can progress further into the shared tubes and lead to liver or pancreas backup and damage to the organs. The issue is that we don’t know what stage the patient is in the process, and the only way to learn for sure on a Saturday morning was with an ER evaluation.
The patient asked for other options, including outpatient evaluation and workup with in-house blood work and imaging, which would likely not be until Monday morning at the earliest. It was reiterated that there was a risk to this choice as the level and severity of the disease state are not known and could progress or worsen before that time.
The visit punctuated what the expected ER workup might involve, with a disclaimer that the ER will work it up as they see medically fit. There was also the addition that there was hope the ER workup was negative and the patient went home from the ER with a clean bill of health or the known diagnosis of GERD, as this would be the best-case outcome of an ER visit.
After being thoroughly informed and involved in the decision-making process, the patient opted to go to the ER for further evaluation. That evening, the patient underwent a cholecystectomy.
Do not delay a truly emergent visit, such as crushing chest pain or facial drooping, to provide this level of care.
If the example patient had opted for an outpatient workup, the appropriate response would have been to reiterate this decision goes against medical advice. The provider would have them sign the AMA form and treat them as best as possible within the bounds they have set with their patient autonomy.
In the example case, labs, an immediate right upper quadrant (RUQ) ultrasound, and a surgical consult as soon as possible would be needed. The patient may have been persuaded to visit the ER with a RUQ ultrasound, which demonstrated cholecystitis.
Don’t be afraid to tell a patient:
As a healthcare provider, I don’t ever want to miss something. The ER can do a more complete workup than I can do here in an urgent care setting. I would rather you go, and they find that your gallbladder is fine, than to miss a more serious problem. If they say everything is ok, then you have the best possible outcome. However, we don’t know for sure unless you go to the ER.
Our patients want to be heard, validated, examined, and cared for, as we all desire. When they enter our clinics, some of them know they likely should have gone to the ER, and they are scared.
We often see people on what may be the worst day of their lives, so remember to listen carefully, evaluate thoroughly, and treat them with the kindness and professionalism you’d want to be shown to yourself or a family member—even when you know they require a higher level of care.
Daniel Ralston, MD
Regional Medical Director
Peachtree Immediate Care
E-mail: dralston@peachtreemed.com
Herpes zoster is a reactivation of the varicella-zoster virus (VZV), more commonly known as shingles. It can occur with natural infection or after immunization to varicella, although immunization-mediated zoster is less frequent. The reactivation can occur in any age group or demographic.
The primary risk factors for herpes zoster are increasing age and immunosuppression.
The clinical manifestations are typically a painful, one-sided, and dermatomal rash that begins with erythema or erythematous papules, progresses to erythematous vesicles or bullae, and can then become pustular. Pain is often described as burning, throbbing, or stabbing and may be present before any skin manifestations.
The thoracic dermatome is the most common location for this rash to present. The approximate breakdown for commonly involved dermatomes: thoracic (53%), cervical (20%), and trigeminal (15%), including ophthalmic and lumbosacral (11%). While rarer, multiple, usually contiguous, dermatomes or sides can be affected.
Herpes zoster should be on your differential diagnosis for any one-sided and dermatomal rash, and even a consideration should be made if it crosses the midline or is in two contiguous dermatomes. If it is in your differential diagnosis, then because of the complications that can happen from shingles it needs to be ruled in or out and accounted for in your treatment. This can be done with a viral culture of the rash, treating with one of the approved treatments, or ideally doing both when possible. The goal is to prevent or lessen any complications.
It should be noted that herpes zoster, especially in early disease presentation, can mimic cellulitis. It is thus sometimes necessary to run a bacterial culture, viral culture, and treat for both a cellulitis and herpes zoster while cultures are pending and then narrowing coverage based on culture data. This is especially true in high-risk areas, such as the ear or face.
The complications of shingles depend partially on location but can be devastating. Post-herpetic neuralgia occurs in 10-20% of cases. Other complications include, but are not limited to, herpes zoster ophthalmicus, herpes zoster oticus (Ramsay Hunt syndrome), aseptic meningitis, encephalitis, and Guillain-Barre.
The above paragraph discussed the use of viral cultures for the rash in the evaluation of shingles. Additionally, if a rash is noted in the first or second branches of the trigeminal nerve, a fluorescein stain should be performed in the clinic to exclude dendritic involvement, and the patient should follow up with an ophthalmologist. Similarly, lesions of or near the ear require otoscopic evaluation and close ENT follow-up.
Treatment is one of three approved agents: valacyclovir, acyclovir, and famciclovir. Most providers prefer valacyclovir and famciclovir for fewer daily doses, but some patients find that acyclovir carries a lower financial burden. The goal of treatment is to lower the duration and severity of illness and the risk of complications. For uncomplicated zoster, the evidence does not currently support a role for any adjunctive therapy such as gabapentin, TCAs, or glucocorticoids. It is still utilized in complicated zoster cases such as Ramsay Hunt or herpes zoster ophthalmicus, although the evidence behind this and which dosing to use is contested.
The prevention of shingles is done via vaccination. The only vaccine currently on the market in the United States is Shingrix. The vaccine is indicated for all patients age 50 and older and can be given, even if the patient has had a herpes zoster outbreak before. The vaccine reduces the incidence of shingles and post-herpetic neuralgia. In the two largest trials, Shingrix reduced the risk of developing herpes zoster by 90-97% and post-herpetic neuralgia by 89-99%.
Daniel Ralston, MD
Regional Medical Director
Peachtree Immediate Care
E-mail: dralston@peachtreemed.com
The goal of this review is to briefly review the history, physical, workup, and treatment specific to acute diarrhea in the urgent care clinical setting. Acute diarrhea is limited to less than 14 days. Below is not the complete chart of a patient with diarrhea but simply specific items that must be done for diarrhea.
Diarrhea for 1-3 days should be considered viral as 73% are viral.
Diarrhea for 3-6 days should be considered bacterial as the percentage shifts from viral to bacterial.
Diarrhea for over 6 days is more likely to be parasitic and must send stool studies, as noted below.
How many days has diarrhea been present, and is the severity improving, worsening, or the same?
How many stools per day, volume of stool, and if there is a particular smell?
What is the color and consistency of stool (blood, mucus, watery, semi-solid, etc.)?
Has the patient had exposure to others with a similar illness?
Has the patient recently taken antibiotics or are they a healthcare worker?
Fever with Tmax if present, light-headedness, abdominal pain.
Cardiac disease, immunocompromise, inflammatory bowel disease, and pregnancy.
Volume status (vitals, mucus membranes, skin turgor). Complete abdominal pain.
Urinalysis can aid volume status. Chemistry panel if the volume is very depleted.
Stool studies are indicated if more than 1 week, more than 6 stools a day, severe abdominal pain, hypovolemia, bloody diarrhea, high fever, and comorbid conditions listed above.
https://www.aafp.org/pubs/afp/issues/2014/0201/p180.html (prior issue and free to access)
https://www.aafp.org/pubs/afp/issues/2022/0700/acute-diarrhea.html (most UTD but requires AAFP membership)
E-mail: dralston@peachtreemed.com
When a patient comes in to be evaluated following a motor vehicle accident, it is important to provide detailed documentation. Patients will often need these reports for their lawyer and car insurance if they have med pay coverage. Remember, private insurance usually does not pay for motor vehicle accidents, so the patient may have to pay out of pocket.
Document all body parts that were injured, no matter how small (abrasions, cuts, minor aches and pains). The most common injuries are muscle sprains and spasms to the back and neck, along with bruising/contusions and concussions.
Make sure you or the MA complete the entire MVA box in the context section.
Add as many details as possible about the accident such as weather conditions; time of day; who was in the vehicle; describe what happened; who got the ticket; the extent of the damage and where it is on the vehicle; if the patient was ambulatory at the scene; ER visit and findings and how the patient was transferred (POV vs EMS); if the seatbelt was used; if the airbag was deployed; if EMS was on the scene; if any prior injuries to injured body parts.
Ask about loss of consciousness (LOC). Was there an initial brief LOC followed by a lucid phase and then another LOC episode or focal change? This indicates a bleed, and the patient should be sent to the ER for further workup and CT imaging.
Regarding the timing of symptoms, remember that fractures and torn ligaments or tendons result in immediate pain. Neck and back pain from muscle spasms, which most MVAs will have at some point, are gradual over 24 to 48 hours. If the patient states there was no pain on the day of the accident and the pain came the next day, this can reassure that the patient is most likely experiencing a muscle spasm rather than fractures or something torn. You still must do a thorough workup.
The most important part of evaluating a patient in an MVA is the physical exam. Examine all areas injured, including the skin.
One of the most important exams you can do for an MVA patient is to check reflexes when there is concern for a spinal injury, like a disc herniation. If the reflexes are reduced, then the patient is more likely to have a herniation or nerve compression on the affected side.
Look for red flags for back pain and send to the ER if present. There is a big difference between paraspinal muscle pain and posterior spinous process pain. Anyone with posterior spinous process pain should have a CT of that area, as 50% of spine Fx can be missed on plane film. Anyone without spinous process pain and just paraspinal muscle pain can have an X-ray with any tenderness over the affected area.
Look for signs of burns if an airbag was deployed.
If there was blunt force trauma to the head or LOC, do a thorough neuro exam and look for signs of a concussion (Concussion Impact Questionnaire) or subdural/epidural hematoma.
Blunt force trauma to the chest and/or chest pain and should be sent to ER if:
Blunt force trauma to the abdomen:
For symptomatic patients do a UA and look for blood, a pregnancy test for child-bearing women, and an abdominal ultrasound for any of the above.
Make sure you provide specific diagnoses for all body parts injured, and not just pain to a body part. It is preferable to use codes for contusions, sprains/strains, abrasions, etc.
It is good to include a diagnosis for the type of accident itself. For example, there is a general code for an encounter for the exam and observation following a transport accident (Z04.1). There are specific V codes for the type of accident as well. The code for a person injured in an MVA is V89.2xx. However, you can be more specific as to the type of vehicle and if the patient was the driver or the passenger. For example, you can use V86.05 for the driver of 3-4 ATVs injured in a traffic accident.
Document the management plan for each injury. Refer to specialists, physical therapy, imaging, and the ER appropriately. Inform patients that it may take 24 to 72 hours after an accident before new pain develops or the current pain worsens.
Manage pain by alternating OTC Tylenol and Ibuprofen every 4 to 6 hours, which will also help reduce inflammation in strained muscles. Consider muscle relaxers for suspected muscle spasms; most will develop this over the first 24 to 48 hours.
Stretching exercises should be provided to increase blood flow and oxygen to the muscles.
Apply heat to relax muscles and topical analgesics like Bio Freeze or Icy Hot.
Follow appropriate rules for determining if X-rays are needed:
Refer to the ER if the patient had a brief LOC/concern for a bleed, focal neuro signs, was involved in a high-impact collision, or the vehicle was totaled.
Any patient not sent to the ER should have another follow-up visit in the clinic no later than 48 hours. This is the time when all the inflammation and muscle spasms will occur but at its max. You should re-evaluate them then.
Send to the ER if the patient has now or develops at home:
Check out the September 2009 edition of the Journal of Urgent Care Medicine for more on the topic of assessing patients after a motor vehicle accident.
E-mail: kmanlovesimmons@peachtreemed.com
