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? 

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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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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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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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