Plain X ray in suspected bowel obstruction. Is that all?

Clinical Scenario

A 67 y/o woman arrives in the ED at 5pm because of diffused abdominal pain since 2 hours. She has nausea and she refers costipation from the day before. 

She has a history of hysterectomy 5 years before because of fibroma.

Vital signs are normal, she presents pale and sufferer for pain, the abdomen is distendend and palpation cause pain all over it. 

Bowel movements are present but abnormal. 

Plain x ray shows 2 little fluid levels without the evidence of dilated loops of bowel, so radiologist describe it as negative.

Has plain x ray changed your previous clinical judgment about the suspect of bowel obstruction?

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Sick or not-sick at a glance. Is it reliable?

Clinical scenario

It’s a busy Monday morning in ED, many ambulance are on the go. There’s been a car crash on the high street - says the nurse – we must free the rooms immediately.    There is a full flow now. In a box there is a young man, the doctor observes the patient form the outside, the computer says “dyspepsia and fever”. Blood pressure, temperature, oxygen saturation, heart rate and respiratory rate are normal.
After few seconds of observing, the doctor ask the nurse to invite the patient to leave the room for the arrival of a newer patients. I think he isn’t sick, he can wait - he says.
 In the last room there is an old man just transported from an assisted-living facility because of dyspnoea, fever and cough. Respiratory rates are about 25. A rapid look than the doctor orders for a rapid admission in a non intensive care unit.

How reliable is the first look?

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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.

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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?

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Is it a subtle appendicitis? How to make time your friend

Clinical Scenario

Mr. Smith is a 39 yo man with abdominal pain. He has been visited, few hours ago, by his primary care doctor who sent him to you for a surgeon consult. He refers abdominal pain, fever and nausea since the day before. The pain was previously in the midabdomen, than it migrated to the right lower quadrant (RLQ). 

Temperature is 38°C, he is tachicardic, he has a moderate pain in RLQ, there aren’t signs of peritonitis.  Appendix  Is not visualized at US examination.  

Laboratory evaluation reveals WBC count 12.000 (cells/microL)  and CPR 7 (mg/L) . 

Patient’s presentation is suggestive for appendicitis but not clearly diagnostic. Let’s see what the surgeon advices.

“He is not yet ready for the operating room” he says “it’s better to repeat a laboratory evaluation, please call me in four hours”. 

The patient is admitted to observation unit. 

How will the change of laboratory tests help you after four hours?  

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Do you suspect a lower UTI? Urine analysis sometimes is over!

Clinical Scenario

A 30 yo woman comes in ED complaining a burning pain when urinating, hematuria  and increased of urinary frequency.  She denies abdominal pain, fever, and vaginal discharge, she is not pregnant. 

On the right there’s the toilette – the nurse indicates – could you pee in this cup?

Give me antibiotics – she says – it’s a cystitis, I know it, I have to return early at work!

Are history and physical examination sufficient to prescribe antibiotics?

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Headache and Subarachnoid haemorrage. How and how long your pain started?

Clinical Scenario

A young healthy man presents to the ED because of acute onset severe headheache. The pain has started the day before while he was swimming, he refers the worst headache of his life, neurological examination and vital signs are all normal. Head CT is also normal. After therapy and short clinical observation he feels better, but the pain continues, even if less, neurological examination is still normal.

May this patient has a subarachnoid haemorrage (SAH)?

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Sciatica: only pain control, or imaging? Point your big toe to your nose!!!

Clinical Scenario

A 50 y/o friend of yours called for you. He refers low back pain radiating to his left leg from approximately 2 weeks. “help me doc - he says -  I have a sciatica, a dog is biting my buttock, can you favor me with an urgent RMN?”. He is very suffering. During the straight leg raise test (SLR) he develops pain down the left leg to 30-40 degree. The crossed straight leg raise test (CSLR) is negative. There are no changes in bowel or bladder habits. 

“Point your big toe to your nose” - you ask putting the hand on the your friend’s feet .

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Is it always necessary to perform an arterial blood gas after a blunt trauma?

   Clinical Scenario

A 53 year old man is involved in a motor vehicle crash. He refers a moderate thorax and abdominal pain. No head injury, the helmet is not broken, the patient remembers the accident. Systolic blood pression is 120/80 mmHg, respiratory rate is 24, saturation is 100%, he has abrasions over the torso and right thorax and flank, no wounds. The eFAST shows a normal pleural sliding, and no signs of intraperitoneal blood.

 The institutional blunt trauma protocol requires an arterial blood gas (ABG) and serum lactate (SL), than is obtained a CT of the chest abdomen and pelvis. 

After 15 minutes, the patient returns to the ED, TC is negative, the patient feels better, the nurse says that the ABG is abnormal, pH is 7.5 and lactate level is 4. 

Do abnormal ABG and/or SL change disposition after a negative CT?  

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PCT and pneumonia: worth it?

Clinical Scenario

A 78 yo woman is brought from an assisted-living facility because of dyspnea and fever. 
She has an history of dyabetes and heart failure. She is confused, tachipnoic, tachicardic and febrile with rales on the back. Chest X ray shows an infiltrate. PCT value is 1,5 µg/L. 



Does PCT provide prognostic information concerning mortality risk or adverse event in pneumonia? 


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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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Useless ECG?

Clinical Scenario

A 67 y/o man arrives to the ED by ambulance because of precordial pain since half an hour, during the transport, paramedics perform an ECG that shows a left bundle branch block (LBBB), that patient refers in his history.

They find it unuseful and so they do not transmit it to the cardiologist, is it correct?

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Is it broken?

Clinical Scenario

Anthony, a 15 y/o student, slipped and fell while playng soccer. The next morning he refers continue pain on the right elbow. “Is it broken?” ask Anthony and his father at the triage desktop?

There is pain and edema near the elbow, no radial pulse deficit, he can fully extend and flex the articulation, there aren’t problem about prono-supination.

The doctor smiles and reassures Anthony and his father, “it’s not broken, RICE is enough!!!”.    

  

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