Chest X-Ray and aortic dissection

Clinical Scenario 

A 70 yo man come to the ED for restrosternal chest pain and shortness of breath during minimal activity in the last days. He is an ex smoker, with a history of hypertension. On physical examination the patient is not in distress, with a regular blood pressure and regular oximetry. ECG shows no evidence of ischemia. You first think about coronary artery disease, but you also want to exclude an aortic dissection. In Radiology the patient remaine seated and receive an anteroposterior (AP) chest Xray: maximal mediastinal width (MW) is 8,80 cm (the optimal cutoff level is 8,65 cm), no other signs. 

Shall you worry?

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Is CRP correlated to CT result in the evaluation of abdominal pain?

A 74 yo/man complained of diffuse abdominal pain. The pain was intermittent and accompained by vomiting. He has no history of abdominal pain or abdominal surgery.

On examinations the patient presented non icteric, afebrile, not tachicardic. 

The abdomen was mildly distensed with midline tenderness. 

The US evidenced a normal aorta diameter. 

Abdominal x ray showed non specific bowel gas pattern. 

CRP value was 7 mg/L.

The radiologist says it is a little value to perform an abdominal CT, we see tomorrow…..

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How LR works. Why any test is unnecessary for a patient with very low-risk chest pain ?

A 40 yo truck driver, presented in ED with substernal chest pain. He is healthy, no family history of CAD. Held for observation, serial ECG have not modified, not elevated troponin.

Is an Exercise Treadmill Testing useful (ETT)? Or a Myocardial Perfusion Imaging (MPI) is better ?

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Does Murphy’s sign and sonographic Murphy sign have the same clinical utility?

A 40 yo woman presented to the ED with upper quadrant pain since three hours after eating a tasty pizza. She is overweight, she presents feverish (38°C) her skin is nonicteric. The abdomen is soft, there is tenderness on the upper right quadrant, you perform a deep palpation in the subcostal area, and the patient stops breathing for pain. 

Is Murphy’s sign useful to make diagnosis of cholecystitis? What about the sonographic Murphy’s sign?

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Diagnosis of pneumonia. Is it the time for a combined imaging strategy?

A 80 yo man is brought from an assisted-living facility because of fever, productive cough, tachycardia and dyspnoea. 

He has a history of dementia and hypertension.

He is cachectic, you hear ronchi on the left side. 

How should you approach this patient?

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Rectal Examination and Appendicitis

A 25 y/o man comes to the ED because of abdominal pain started 2 hours before, fever and vomit.

He has not history of disease, no history of surgery, no history of other ED admission for abdominal pain.

Clinical examination shows rigidity and diffused painfull abdomen.

You perform digital rectal examination were you evidence no pain in the Douglas space and normal stool, can you exclude appendicitis?.

Conclusion 

Digital rectal examination (DRE) is not necessary in patients with suspected acute appendicitis, it provides no additional information that is not available on the abdominal examination.

It is not useful in comparison with the discomfort and privacy problems that often accompany its use, it can be very unpleasant for the patient. 

There is also poor evidence regarding the clinical utility of the DRE in the diagnosis of undifferentiated abdominal pain.

Bibliography 

R. E. B. Andersson

Meta-analysis of the clinical and laboratory diagnosis of appendicitis

British Journal of Surgery 2004; 91: 28–37

J Quaas , M Lanigan, D Newman, J McOsker, R Babayev, C Mason

Utility of the digital rectal examination in the evaluation of undifferentiated abdominal pain

American Journal of Emergency Medicine (2009) 27, 1125–1129

S A Colucciello, T W Lukens, D L Morgan 

Assessing Abdominal Pain In Adults: A Rational, Cost-Effective, And Evidence-Based Strategy

Emergency Medicine Practice, Premier Issue Volume1,Number1, 1999

N Manimaran, RB Galland

Significance of routine digital rectal examination in adults presenting with abdominal pain

Ann R Coll Surg Engl 2004; 86: 292–295

Ilenia Spallino

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Bowel obstruction and physical examination

A 75 y/o man arrives in ED from a nursing. 

He complains abdominal pain. 

No fever, no jaundice, abdomen presents distended. 

Inspection shows a midline old scar,

there is diffuse rigidity, 

increased bowel sounds and vomit on the sheets. 

Can history and clinical examination contribute to diagnosis of bowel obstruction?

Conclusion 

Medical history and physical examination are a good method in evaluation of a patient with a suspected bowel obstruction. Age > 50 years, distended abdomen, increased bowel sounds, vomit, history of costipation,  previous abdominal surgery  alone can increase the probability of bowel obstruction. The combination of three of this has a very high LR+ from 19 to infinity! Although in some case clinical examination could be diagnostic of bowel obstruction without any other investigation, the practice of plain radiography is still very diffused….what about it?

Bibliography 

H Bohner, Q Yang et al:

Simple data from history and physical examination help to exclude bowel obstruction and to avoid radiographic studies in patients with acute abdominal pain. 

Eur J Surg 1998; 164:777-784

to be continued...

Ciro Paolillo and Ilenia Spallino

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