How have you come to the hospital?

Clinical Scenario

It’s just started your night shift, Sara is a young EP, she is going home after an hard day.  Hello - she says tired - could you help me? There is a guy with abdominal pain and nausea. I think it could be appendicitis, but there is not fever and not leukocytosis. 

Have you asked if he arrived by car? - You say

No, why? 


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Imaging strategies of suspected acute colonic diverticulitis: how does it work?

Clinical scenario

A 66 yo man complains of left lower quadrant (LLQ) pain, anoressia and fever, it is the first time. The pain is acute, there is not vomit, temperature is 38°C. Abdomen is treatable, with severe pain and tenderness localized at LLQ , there is not history of prior abdominal surgery. Probably this patient suffers of an acute colonic diverticulitis (ACD).

Is Computer Thomography (CT) the imaging procedure of choice for this patient? 

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To fill or not to fill? Try to raise the legs...

Clinical Scenario

A 54 y/o man is brought to the ED because his wife has found him semiunconscious in the morning, he has  not significant clincal history and does not take medicaments, he presents hypoperfused, arterial pressure is 90/50 and MAP is 63, lactate is 7 mmol/L and hemoglobin is 14 g/dl. Inferior vena cava diameter is 1,5 cm. Respiratory variation of inferior vena cava is about 25%

Yours is a diagnosis of shock, your dilemma is if he will respond or instead be harmed by fluid administration, you a have a 50% possibility, you can flip a coin or maybe raise the patient’s legs….

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Diagnosis of diverticulitis with hands and blood tests. Is it a good idea?

Clinical Scenario

A 66 yo man complains of left lower quadrant (LLQ) abdominal pain from 4/5 hours. The pain is described as crampy initially, than continuous, there is not vomit. Temperature is 37.5°C. Abdomen is treatable, with moderate pain and tenderness localized at LLQ , there is not history of prior abdominal surgery. 

ED US excluded the specter of an AAA.

WBC 13.000/μl

CPR: 51 mg/L

Probably this patient suffers of an acute diverticulitis. 

Is it an urgent imaging necessary to confirm the diagnosis? 

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Is CRP useful alone to support the hypotesis of a bacteremia?

Clinical Scenario

It’s a very cold February, but ED is very hot in every sense of the word. 

A 22 y/o student refers stomach pain, chills, fever and diffuse muscolar pain. He has fever (38° C) there is a mild diffuse abdominal pain. 

The CRP value is 30 mg/L. 

Are there flu symptoms, or it is a bacteremia?

Can we use the CRP test for change our clinical suspicion? 

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Malaria or just fever?

Clinical Scenario

A 35 y/o man is brought to the ED by friends and left there alone, he has high fever, he is from Ghana and he has just arrived, he speaks english not so well and he is confused and agitated, so anamnesis is very difficult and you catch a only word “malaria”, you also know that africans often calls malaria every fever, but …

Clinical examination is normal except for the agitation state, but fever is very high (40,5°C), he has not headhache, no cough, no abdominal pain. It is night and microbiologist is not available for malaria microscopy test and you decide to perform, for the first time in your life, the rapid test…it is negative…

Can you trust it or the patient?

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Is chest X ray necessary to rule out PNX after thoracic maneuvers?

Clinical Scenario

It’s a busy day in ED this morning. 

The first patient refers dyspnoea, he has an advanced pulmonary neoplasia, ultrasound and chest x-ray confirm that the left zone is occupated by a pleural effusion. The thoracentesis removes about 1.5 liter of fluid, the patient breathes easily.

The second patient is 65 yo, he has pneumonia, he is septic, it’s impossible to find a vein, the right internal jugular vein is identified by ultrasound and the catheterization is performed without any problem.   

Is it necessary in this cases to perform a chest  X-ray to rule out a PNX?

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