A life at risk: the Emergency Physician

1/01/2016

Blood test and urgent abdominal conditions

Clinical Scenario

A 44 YO man presents to the ED complaining of abdominal pain. He was well until 4 hours ago, when he developed diffuse abdominal pain. This is the first time he suffers abdominal pain. He has not history of surgery.

The patient is afebrile, HR is 80, BP is 180/100, ECG is normal. The abdomen is very painful, but soft.

Is it a serious condition? Asks the worried man.

“We’ll see later, after blood test” says the doctor.

Conclusion

WBC count and CRP levels alone or together are insufficient markers to be used as a triage instruments to select an urgent from non-urgent abdominal condition. In several circumstances like acute appendicitis or acute diverticulitis o cholecystitis WBC count and CRP levels can be normal.

Blood test alone are of limited use.

Bibliography

SL Gans

C-Reactive protein and white blood cell count as triage test between urgent and non urgent conditions in 2961 patients with acute abdominal pain.

Medicine 2015 vol 94 n 9 1-9.

C Paolillo, I.Spallino

Can C-reactive protein and white blood cell count alore rule out an urgent condition in acute abdominal pain?

Intern Emerg Med 2015 oct 27.

Ciro Paolillo

4/27/2015

Where is peritonitis?

Clinical Scenario

A 80 YO man with a history of hypertension presents to the ED complaining of abdominal pain. He felt well until 8 hours ago, when he developed diffuse abdominal pain. The patient is afebrile, tachicardic, BP is 180/100 his lungs are clear, ECG shows no changes suggestive of ischemia. There is diffuse abdominal rigidity.

In another room there is a 22 yo girl with abdominal pain started two days before. She is febrile (38°C) and tachicardic, blood pressure is 120/80, her abdomen is soft. The cough test is positive, but rebound is negative.

In the 3rd room there is a 48 yo patient. Come in -says the nurse- this abdomen is like a board.

Where is peritonitis?

1/19/2015

Run to the operation room!

Clinical Scenario

A 70 yo woman is brought to the ED by ambulance.

She’s suffering from vomit, lach of flatus and abdominal pain since 24 hours says the nurse.

She’s pale, the abdomen shows a midline scar. There is diffused tenderness with rebound.

Abdomen US and X rays show abnormal distended loop of small bowel.

Ok, Ok I saw the images, there’s an occlusion says the surgeon at phone but, you know, I need a CT!

Are there CT findings that identify patients requiring a run to the operation room?

12/25/2014

My heart hates Christmas

Clinical Scenario

It’s 7 pm on Christmas day, a 32 yo woman refers palpitations since the morning. I was with my frends yesterday nigth, I think I had drank a bit too much. I Hate Christmas, it brings me down.

She’s awake, alert and oriented, her mood is low. Vital signs are normal, EKG shows a sinus rhythm.

I’m sure it’s nothing but this damn holidays…

10/24/2014

NO fever, NO bacteriaemia?

Clinical Scenario

A 80 yo nursing home resident woman is brought to the ED by ambulance.

“Hypothension, cough and a hystory of heart failure ”, refers the nurse.

She looks pale and confused, her respiratory rate is 22, oxygen saturation on room air is 90%. Ear temperature is 36,5°C, BP is 90/60 mmHg, HR is 95.

There’re pulmonary rales. Lactate are 4 mmol/dl.

Is it a low flow heart failure or is there and underline pneumonia? Does the absence of fever rule out bacteriaemia?

8/06/2014

Diagnosis of scaphoid fractures.  Are plain radiographs reliable?

Clinical Scenario

It’s a busy wednesday morning in ED.

A 18 yo guy presents with the right hand upraised and dressed.

In the other hand he has a bundle of X ray.

“About ten days ago, it was a Saturday night, I was with my new girl-friend. Hitting a punch bag as hard as possible I felt pain to my right wrist. My doctor ordered wrist X ray. It’s not broken, he says, but I’m very afraid, when I move the wrist it pains me so much”.

On clinical examination there is snuff box tenderness, the axial loading maneuvre on the thumb is positive (see previous post).

The emergency phisician takes an accurately look at the X rays. They are of high quality, the study had 4 views of the scaphoid, there’s no evidence of irregularity of cortex, the scaphoid fat pad seems normal.

“Repeat X-ray” orders the doctor….

6/28/2014

Is a cold steak enough in black eye?

Clinical Scenario

A young guy comes to the ED after a car crash. While he was driving, the car in front of him stopped abruptly so they crashed. Fortunately speed was low and he does not report major trauma, but a black eye due to an impact towards the airbag. You promptly evaluate his sight and find no deficit, no diplopia, palpation does not show fracture steps or enphysema, skin sensation is preserved.

It’s nothing, just put a cold steak on it!

Would you really say this?

6/16/2014

Is my hand broken?

Clinical Scenario

A 24 y/o guy presents in ED with the left hand upraised.

“I fell off my bike yesterday – he says – I remember a serious impact with an outstreched palm.”

There aren’t wounds, he feels pain on the radial side of left wrist, there is an anatomical snuffbox tenderness. The clamp sign is positive, but the resisted pronation maneuvre and the longitudinal compression test are negative.

(see the video if you don’t remember the maneuvres)

Is it broken? Asks worried the guy.

4/11/2014

Ottawa ankle rules.  Does it really work?

Clinical Scenario

A 16 yo guy is brought in ED by his mother after a scholar accident.

While he was running, he crashed.

My son has a sore ankle! Is it broken? Asks the mother seriously worried.

The ankle his slightly tumefied, there isn’t bone tenderness at the posterior edge or tips of either malleolus, neither there is pain during the pressure of the navicular bone or the base of the fifth metatarsal.

Are you able to take 4 steps? - asks the doctor.

2/09/2014

Does every shoulder pain means magnetic risonance?

Clinical Scenario

A 35 y/o male come to the ED because of pain in his right shoulder, he refers the pain started some month ago during a tennis match, the pain continued but it wasn't so high so he kept playing in the last months, now it is worse. "My tennis mate told me I should perform a magnetic resonance, because it might be a rotator cuff disease" (RCD).

You listen to the patient but decide first to act as a physician and make the old and fascinating physical examination...

What you find is a normal movement of the shoulder, no pain in abducting the arm (arch test), no weakness or pain in internal and external rotation. (see video)

And so what?

1/24/2014

Alarm symptoms and gastric cancer. Are they alarms or they are alarming?

Clinical Scenario

It’s a busy Monday morning in ED.

A doctor at the phone – calls the nurse – there’s a primary care physician.

Hi – says a voice on the other side – I’m in a patient’s home.

He’s a 40 yo man with dyspepsia, his wife refers weight loss of about 10 Kg in the last three months. He is pale, but not tachicardic, abdomen is treatable, on rectal examination I find normal stool.

I’m warried he probably has a gastric cancer, Is it possible to schedule an urgent gastroscopy for this morning?

1/15/2014

Age of 45 and dyspepsia.

Clinical Scenario

It’s the begining of another night shift in ED. Rik, an agreable young colleague approximates: Hi- he says – I have just seen a 60 y/o man who refers epigastric pain since 2 days. He denies bleeding and weight loss, he isn’t anemic. The bedside US shows a normal gallbladder and a normal abdominal aorta, ECG is OK. It seems an uncomplicated dyspepsia, but he is a 60y/o, I’m worried about a grastric cancer.

1/07/2014

Clinical diagnosis of gastric ulcer.  Does your gastroenerologist perform better?

Clinical Scenario

A 35 yo smokerman presents at morning to the ED. He refers epigastric pain since seven days. The pain worses after eating, he refers nausea without vomit and he denies melena and weight loss.

Palpation causes pain in epigastric region, there’s not fever, nor tachicardia, hemoglobin is 13 g/dL.

Bedside US evidences a normal gallblader.

Take antiacid said my doctor and don’t smoke – he says – I’m worried, Is it an ulcer? I wish to consult a gastroenterologist.

11/23/2013

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?

10/20/2013

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?

9/15/2013

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.

9/05/2013

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?

8/24/2013

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?

8/03/2013

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?

7/18/2013

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)?

Subscribe to: Posts (Atom)