Sciatica: only pain control, or imaging? Point your big toe to your nose!!!

Clinical Scenario

A 50 y/o friend of yours called for you. He refers low back pain radiating to his left leg from approximately 2 weeks. “help me doc - he says -  I have a sciatica, a dog is biting my buttock, can you favor me with an urgent RMN?”. He is very suffering. During the straight leg raise test (SLR) he develops pain down the left leg to 30-40 degree. The crossed straight leg raise test (CSLR) is negative. There are no changes in bowel or bladder habits. 

“Point your big toe to your nose” - you ask putting the hand on the your friend’s feet .

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Is it always necessary to perform an arterial blood gas after a blunt trauma?

   Clinical Scenario

A 53 year old man is involved in a motor vehicle crash. He refers a moderate thorax and abdominal pain. No head injury, the helmet is not broken, the patient remembers the accident. Systolic blood pression is 120/80 mmHg, respiratory rate is 24, saturation is 100%, he has abrasions over the torso and right thorax and flank, no wounds. The eFAST shows a normal pleural sliding, and no signs of intraperitoneal blood.

 The institutional blunt trauma protocol requires an arterial blood gas (ABG) and serum lactate (SL), than is obtained a CT of the chest abdomen and pelvis. 

After 15 minutes, the patient returns to the ED, TC is negative, the patient feels better, the nurse says that the ABG is abnormal, pH is 7.5 and lactate level is 4. 

Do abnormal ABG and/or SL change disposition after a negative CT?  

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PCT and pneumonia: worth it?

Clinical Scenario

A 78 yo woman is brought from an assisted-living facility because of dyspnea and fever. 
She has an history of dyabetes and heart failure. She is confused, tachipnoic, tachicardic and febrile with rales on the back. Chest X ray shows an infiltrate. PCT value is 1,5 µg/L. 



Does PCT provide prognostic information concerning mortality risk or adverse event in pneumonia? 


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How have you come to the hospital?

Clinical Scenario

It’s just started your night shift, Sara is a young EP, she is going home after an hard day.  Hello - she says tired - could you help me? There is a guy with abdominal pain and nausea. I think it could be appendicitis, but there is not fever and not leukocytosis. 

Have you asked if he arrived by car? - You say

No, why? 


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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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To fill or not to fill? Try to raise the legs...

Clinical Scenario

A 54 y/o man is brought to the ED because his wife has found him semiunconscious in the morning, he has  not significant clincal history and does not take medicaments, he presents hypoperfused, arterial pressure is 90/50 and MAP is 63, lactate is 7 mmol/L and hemoglobin is 14 g/dl. Inferior vena cava diameter is 1,5 cm. Respiratory variation of inferior vena cava is about 25%

Yours is a diagnosis of shock, your dilemma is if he will respond or instead be harmed by fluid administration, you a have a 50% possibility, you can flip a coin or maybe raise the patient’s legs….

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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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