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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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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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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Acute appendicitis and signs

A 21 y/o man presents to the ED with pain in right low quadrant (RLQ) , anorexia, nausea and vomiting. His abdomen is soft, with a mild tenderness in RLQ, the psoas sign is positive. The pain is aggravate by cough. You perform kindly a rectal examination with pain. 

Are this signs useful for the diagnosis of acute appendicitis?

Conclusion 

No clinical signs alone is able to rule in or out an acute appendicitis. Rectal examination, still diffused, is not of any utility. 

May we need somwthing else?

Bibliography 

Meta-analysis of the clinical and laboratory diagnosis of appendicitis

British Journal of Surgery 2004; 91: 28-37

R.E.B. Anderson

Ciro Paolillo

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