Is it a subtle appendicitis? How to make time your friend (part two)

Clinical Scenario

It’s about the end of  the night shift, in Observation Unit there’s George a 25 yo male presented the evening before with a mild periumbilical pain since 2 days than localized to the right lower quadrant. He was afebrile with stable vital signs, in the car, arriving to the ED, there was vomit, not diahrrea. He had a mild tenderness in RLQ. Labs evidenced WBC of 12.000 (cells/μL)  and CPR of 10 (mg/L). You assessed an intermediate probability of appendicitis, than the guy remained in observation. 

During the night an US of RLQ was performed, and appendix wasn’t visualized, vital signs were stable, there wasn’t vomit, a mild tenderness in RLQ was constant. 

In the morning George feels better, there is no vomit, no fever, the pain is reduced. Labs returned, WBC are increased  (15.000) and CPR is stable. 

Is your assessed probability of an appendicitis changed after an active observation?

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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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Do you suspect a lower UTI? Urine analysis sometimes is over!

Clinical Scenario

A 30 yo woman comes in ED complaining a burning pain when urinating, hematuria  and increased of urinary frequency.  She denies abdominal pain, fever, and vaginal discharge, she is not pregnant. 

On the right there’s the toilette – the nurse indicates – could you pee in this cup?

Give me antibiotics – she says – it’s a cystitis, I know it, I have to return early at work!

Are history and physical examination sufficient to prescribe antibiotics?

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Headache and Subarachnoid haemorrage. How and how long your pain started?

Clinical Scenario

A young healthy man presents to the ED because of acute onset severe headheache. The pain has started the day before while he was swimming, he refers the worst headache of his life, neurological examination and vital signs are all normal. Head CT is also normal. After therapy and short clinical observation he feels better, but the pain continues, even if less, neurological examination is still normal.

May this patient has a subarachnoid haemorrage (SAH)?

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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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