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?

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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.

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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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