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.

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Atypical or typical, is this the question?

Clinical Scenarios

It is a busy day in your ED:

A 60 y/o female refers a retrosternal pain radiates to right arm that lasts more than 20 minutes. 

A 50 y/o male refers a pressure  in his chest, with tachycardia and sweating.

A 75 y/o female refers a sharp and stabbing pain exacerbates by forceful breathing.

In all cases the ECGs are nondiagnostic.

Do these clinical features help to predict an acute myocardial infarction (AMI)?

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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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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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