Can we fight against Pulmonary Embolism using the LR’s arrows?

Clinical Scenario

A 80 y/o woman presented to the ED for dyspnoea.

She underwent a knee replacement 2 weeks ago, RR is 24, O2 saturation is 88%. HR is 90, the knee is edematous.

You are going to hunt a pulmonary embolism (PE)

While you phone the radiologist for a thorax CT scan you have an idea:

Can a compression ultrasonography (CUS) helps to avoid a CT?

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What does it hide behind a negative X-Ray?

Clinical Scenario

A 33 y/o woman, comes to the ED because of a sudden emithorax pain on the left in basal region. The pain is described as stabbing, well localized, it worsen with inspirium …a pleuritic pain, no cough, no fever, not hemoptysis. She smokes, she does not take any medication. 

Chest x ray is normal. You receive blood test: WBC 7.500/mcL, CRP 20 mg/dl , D-dimer 603 ng/ml.

Maybe is not a wall chest pain, but in which direction this test are carrying you?

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Pleuritic pain and radio-occult lesion

Clinical Scenario

A 33 y/o woman, comes to the ED because of a sudden emithorax pain localized on the left in basal region. The pain is described as stabbing, well localised, it worsen with inspirium …a pleuritic pain, no cough, no fever, not hemoptysis. She smokes, she does not take any medication. Chest x ray is normal. 

Is it a wall chest pain or there migth be something else? 

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Does procalcitonin have a role in the management of acute appendicitis?

Clinical scenario

A 18 yo man comes to the ED in the morning because of low abdominal pain, fever and nausea. At palpation there is mild pain in the right inferior quadrant, not guarding.

Could procalcitonin (PTC) helps to exclude quickly an acute appendicitis?

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Is cervical spine X-ray necessary if there is a distracting injury?

Clinical Scenario
 A 40 yo lady arrives in ED by ambulance with neck and spinal immobilization because she fell down a staircare.

 The patient’s vital signs are within normal physiological parameters, she is alert, no deficit, remembers all, denies head contusion and neck pain. She complains for a sharp shoulder pain (NRS 10/10), it seems broken.

If I perform the Nexus C-Spine criteria  X Ray is indicated: a distracting injury mandates cervical spine imaging.

How much the presence of distracting injury reduces my sensibility in rule out cervical spine (c-spine) injury?

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Cellulitis and the role of laboratory

Clinical Scenario

A 72 y/o woman presented to the ED for swollen and painful leg.

Physical examination shows an erythematous, tender and warm leg. 

Probably it is a cellulitis. 

In previous post we stressed the US use to increase diagnostic accuracy. 

Can WBC or CPR help in the differential diagnoses?  

Do they have a role in the decision to admit the patient to the Hospital?  

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Goodbye nasogastric lavage!

Clinical Scenario

A 84 yo woman arrives in ED in midnight coming from a nursing because of a reported episode of coffee ground vomiting. 

Respiratory rate, heart rate and blood pressure are normal, abdomen is not distended, hemoglobin level is 10 g/dl. On rectal examination you find normal stool. 

She takes warfarin. 

Can a nasogasric lavage (NGL) contribute to rule out an upper gastrointestinal bleeding (UGB)? 

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