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Likelihood Ratio (LR) in Emergency Medicine


Low probability of mandibular fracture? C'mon grit your teeth!

Clinical Scenario

It’s a Saturday busy night, in ED when a 31 yo male comes referring pain in the chin and next to the right ear after a trauma. He was out celebrating his birthday, slipped and fell on to his chin. 
Vital signs are normal, there aren’t wounds, he denies malocclusion, the palpation of the anterior ear elicite little pain, there’s not trismus. The tongue and the teeths are intact. 
I’m tired- he says- is my mandibula OK?

I will answer in a little while, says the doctor armed with a tongue depressor.



Is it a subtle appendicitis? How to make time your friend (part two)

Clinical Scenario

It’s about the end of  the night shift, in Observation Unit there’s George a 25 yo male presented the evening before with a mild periumbilical pain since 2 days than localized to the right lower quadrant. He was afebrile with stable vital signs, in the car, arriving to the ED, there was vomit, not diahrrea. He had a mild tenderness in RLQ. Labs evidenced WBC of 12.000 (cells/μL)  and CPR of 10 (mg/L). You assessed an intermediate probability of appendicitis, than the guy remained in observation. 
During the night an US of RLQ was performed, and appendix wasn’t visualized, vital signs were stable, there wasn’t vomit, a mild tenderness in RLQ was constant. 
In the morning George feels better, there is no vomit, no fever, the pain is reduced. Labs returned, WBC are increased  (15.000) and CPR is stable. 

Is your assessed probability of an appendicitis changed after an active observation?