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Chorng-Kuang How

Publications and source records attributed to Chorng-Kuang How.

10 recordsLinked to original sources
PubMed2006

Press through package mis-swallowing.

A press through package (PTP) is commonly used as a package for drugs and also being seen increasingly in cases of foreign body in the digestive tract. We presented three cases of inadvertent PTP ingestion with a variety of clinical presentations. Although commonly considered to be small and soft to cause bowel damage, a PTP tends to be caught and poses potential risk for perforation of the bowel because of its sharp edges. The PTP material is thought to be difficult to detect on plain abdominal roentgenography due to its radiolucency. However, air trapped in the PTP makes the drug tablet possibly visible on the radiograph. All of the three cases were diagnosed with correct interpretation of these special radiographic findings, even without the recall of accidental swallowing of the tablet. A PTP in the oesophagus and stomach should be tried to be removed, while computerised tomography and early laparotomy should be considered when it passes through the pyloric ring and the patient develops symptoms. An effort to prevent the PTP swallowing should be an essential part in our everyday practice, especially for the elderly patients.

Aged↗
PubMed2005

Epigastraglia with tarry stools in a middle-aged female caused by jejunal intussusception due to a hamartoma.

Upper gastrointestinal (GI) hemorrhage is a common presentation to an emergency department. Often, the diagnosis is peptic ulcer disease in which vague or sharp abdominal pain is associated with bleeding. In contrast, intussusception is a rare cause of abdominal pain and coincident GI bleeding. In this case, we report a 41-year-old woman who had an intussuscepting jejunal obstruction due to a hamartoma of the small bowel. The diagnosis was established by ultrasonography. In review of the literature, abdominal pain and bleeding are two common manifestations of intussusception when the lesion originates in the small bowel. Intussusception is frequently included in the differential diagnosis of pediatric patients with coincident abdominal pain and bleeding. However, it is rarely mentioned as an adult cause of these two findings. Because of the delayed and nonspecific presentations of abdominal discomfort in adult patients with intussusception, the diagnosis is often delayed. This case points out the need for considering intussusception even in middle-aged patients whose initial presentation is concomitant bleeding and pain.

Abdominal Pain↗
PubMed2005

Decreasing clinically significant adverse events using feedback to emergency physicians of telephone follow-up outcomes.

STUDY OBJECTIVE: We evaluate the effect on adverse events of a telephone follow-up quality improvement program. METHODS: This was a before-and-after intervention comparison based on prospectively collected data in a tertiary care hospital emergency department (ED) (82,000 visits per year). The first half (April 15 to July 31, 2001) served as control, and the second half (August 1 to November 15, 2001) served as intervention with feedback to physicians on telephone follow-up outcomes of discharged patients and resident training about the uncertain presentations of serious diseases and the need to use additional evaluation on selected patients (observation unit, hospital admission). Telephone follow-up of the high-risk patients and retrospective review of 3-day return visits were used to quantify outcome measures: return visits to EDs and clinically significant adverse events (return visits with serious misdiagnoses or an erroneous management plan). The differences in proportions of outcomes were measured with 95% confidence intervals (CIs). RESULTS: High-risk patients were enrolled: 566 (13.7%) of 4,139 discharged patients in the before-intervention period and 397 (11.3%) of 3,507 in the after-intervention period. The quality improvement initiative decreased return visits on enrolled patients from 10.1% (57/566) to 4.9% (19/397) (5.2% difference with 95% CI 1.8% to 8.8%) and decreased clinically significant adverse events from 4.1% (23/566) to 1.5% (6/397) (2.6% difference with 95% CI 0.3% to 4.8%). For all ED discharged patients, clinically significant adverse events decreased from 0.9% (39/4,139) to 0.4% (15/3,507) (0.5% difference with 95% CI 0.1% to 0.9%). During the study, the observation rate increased 4.3% (95% CI 2.8% to 5.7%), and the admission rate increased 3.4% (95% CI 2.1% to 4.8%). CONCLUSION: A quality improvement program with feedback to physicians of telephone follow-up and resident education can decrease clinically significant adverse events in ED discharged patients.

Diagnostic Errors↗
PubMed2005

A rare case of massive pericardial effusion secondary to hypothyroidism.

Massive pericardial effusions secondary to hypothyroidism are rarely seen in the emergency department (ED). The case of a patient presenting with a relatively asymptomatic massive pericardial effusion due to hypothyroidism is described. The patient had a history of laryngeal carcinoma post-total laryngectomy and adjuvant radiotherapy 12 years previous. Although underlying malignancy was in the differential diagnosis, hypothyroidism was diagnosed through a detailed history and physical examination, thereby avoiding the need for pericardiocentesis. Thyroid replacement alone is sufficient for resolution of these effusions, although it may take many months. Pericardiocentesis is indicated only if cardiac tamponade develops. This rare but significant condition should be considered, especially when it occurs after acute cold exposure.

Aged↗
PubMed2005

Diagnosis of appendicitis with left lower quadrant pain.

Abdominal pain is one of the most common chief complaints of patients presenting to the emergency department and, among the diagnoses of abdominal pain, appendicitis is the most common surgical disorder. Traditionally, the diagnosis of appendicitis is based on well-established clinical criteria combined with physician experience. However, appendicitis presenting with rare and misleading left lower quadrant (LLQ) pain may result in an initial false-negative diagnosis by the physician and even result in failure to order the subsidiary examination of computed tomography (CT) or ultrasound, so increasing the risk of perforation/abscess formation and prolonged hospital stay. In this report, we present 2 cases of atypical appendicitis with LLQ pain where the correct diagnosis was not initially considered. One patient had right-sided appendicitis; the inflamed appendix was 12 cm in length and projected into the LLQ. Local peritonitis developed during observation. With the aid of CT, the diagnosis was established in time. The other patient had left-sided appendicitis with situs inversus totalis. Adverse outcomes with appendiceal rupture and abscess formation occurred due to inadvertent physical examinations and inadequate observation. Early clinical suspicion and adequate observation are indicated in patients with uncertain clinical features. However, in patients with unresolved clinical symptoms and/or local peritonitis that develop during observation, imaging studies play a significant role in preoperative diagnosis and determination of proper treatment.

Abdominal Pain↗
PubMed2004

Hepatic portal venous gas: clinical significance of computed tomography findings.

Hepatic portal venous gas (HPVG) is a rare radiographic finding of significance. Most cases with HPVG are related to mesenteric ischemia that have been associated with extended bowel necrosis and fatal outcome. With the help of computed tomography (CT) in early diagnosis of HPVG, the clinical outcome of patients with mesenteric ischemia has improved. There has been also an increasing rate of detection of HPVG with certain nonischemic conditions. In this report, we present two cases demonstrating HPVG unrelated to mesenteric ischemia. One patient with cholangitis presented abdominal pain with local peritonitis and survived after appropriate antibiotic treatment. Laparotomy was avoided as a result of lack of CT evidence of ischemic bowel disease besides the presence of HPVG. The other case had severe enteritis. Although his CT finding preluded ischemic bowel disease, conservative treatment was implemented because of the absence of peritoneal signs or clinical toxic symptoms. Therefore, whenever HPVG is detected on CT, urgent exploratory laparotomy is only mandatory in a patient with whom intestinal ischemia or infarction is suspected on the basis of radiologic and clinical findings. On the other hand, unnecessary exploratory laparotomy should be avoided in nonischemic conditions that are usually associated with a better clinical outcome if appropriate therapy is prompted for the underlying diseases. Patients with radiographic diagnosis of HPVG should receive a detailed history review and physical examination. The patient's underlying condition should be determined to provide a solid ground for exploratory laparotomy. A flow chart is presented for facilitating the management of patients with HPVG in the ED.

Aged↗
PubMed2003

Tetrodotoxin poisoning.

Tetrodotoxin (TTX) poisoning, although uncommon, is frequently seen in Taiwan, Japan, and Southeast Asia. It is rare but significant in the United States as well. Only three cases have been reported in the EM literature. We report an outbreak of six cases of TTX poisoning from eating puffer fish. On April 17, 2001, an outbreak of TTX poisoning occurred among Mainland Chinese fishermen who shared puffer fish on their boat in the Taiwan Strait. All six cases were middle-aged men (aged 32-49 yr). Onset of symptoms began approximately 2 to 3 hours after ingestion; symptoms included orolingual numbness, acroparesthesia, and breathlessness. As a result of delayed transportation and initial resuscitation, one patient presented in full cardiac arrest, with recovery of spontaneous circulation after successful cardiopulmonary resuscitation. With the exception of this patient, the initial acid-base abnormalities were inconsistent with severity of illness and mild hypercapnia was common (4 out of 5). The patient who presented in full arrest died 1 day after admission as a result of intractable bradycardia (complete atrioventricular block), a finding rarely mentioned in the literature, despite intravenous atropine and dopamine infusion. The remaining patients survived without significant sequelae and were discharged after short-term observation and supportive care, although some had neurologic and cardiopulmonary manifestations (muscle weakness, hypotension, hypoxemia, and hypercapnia). Some mildly hypoventilated patients recovered well without endotracheal intubation and ventilatory support. Favorable outcomes in most patients can be obtained if aggressive supportive treatment is provided in time. Thus, appropriate prehospital and ED ventilatory support (the implementation of a bag-valve mask or endotracheal intubation with good ventilatory support) is mandatory for those patients with respiratory failure. Most patients experience onset of symptoms within 6 hours of ingestion, but a few have a delayed onset up to 20 hours. Therefore, for those TTX-intoxicated patients without immediate prominent respiratory insufficiency, at least 24 hours of intensive monitoring of their respiratory state is necessary because of the different susceptibility and unpredictability of an individual course.

Adult↗