Alarm symptoms and gastric cancer. Are they alarms or they are alarming?

Clinical Scenario

It’s a busy Monday morning in ED. 

A doctor at the phone – calls the nurse – there’s a primary care physician. 

Hi – says a voice on the other side –  I’m in a patient’s home. 

He’s a 40 yo man with dyspepsia, his wife refers weight loss of about 10 Kg in the last three months. He is pale, but not tachicardic, abdomen is treatable, on rectal examination I find normal stool. 

I’m warried he probably has a gastric cancer, Is it possible to schedule an urgent gastroscopy for this morning?

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Age of 45 and dyspepsia.

Clinical Scenario

It’s the begining of another night shift in ED. Rik, an agreable young colleague approximates: Hi- he says – I have just seen a 60 y/o man who refers epigastric pain since 2 days. He denies bleeding and weight loss, he isn’t anemic. The bedside US shows a normal gallbladder and a normal abdominal aorta, ECG is OK. It seems an uncomplicated dyspepsia, but he is a 60y/o, I’m worried about a grastric cancer. 

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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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Plain X ray in suspected bowel obstruction. Is that all?

Clinical Scenario

A 67 y/o woman arrives in the ED at 5pm because of diffused abdominal pain since 2 hours. She has nausea and she refers costipation from the day before. 

She has a history of hysterectomy 5 years before because of fibroma.

Vital signs are normal, she presents pale and sufferer for pain, the abdomen is distendend and palpation cause pain all over it. 

Bowel movements are present but abnormal. 

Plain x ray shows 2 little fluid levels without the evidence of dilated loops of bowel, so radiologist describe it as negative.

Has plain x ray changed your previous clinical judgment about the suspect of bowel obstruction?

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Sick or not-sick at a glance. Is it reliable?

Clinical scenario

It’s a busy Monday morning in ED, many ambulance are on the go. There’s been a car crash on the high street - says the nurse – we must free the rooms immediately.    There is a full flow now. In a box there is a young man, the doctor observes the patient form the outside, the computer says “dyspepsia and fever”. Blood pressure, temperature, oxygen saturation, heart rate and respiratory rate are normal.
After few seconds of observing, the doctor ask the nurse to invite the patient to leave the room for the arrival of a newer patients. I think he isn’t sick, he can wait - he says.
 In the last room there is an old man just transported from an assisted-living facility because of dyspnoea, fever and cough. Respiratory rates are about 25. A rapid look than the doctor orders for a rapid admission in a non intensive care unit.

How reliable is the first look?

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Low probability of mandibular fracture? C'mon grit your teeth!

Clinical Scenario

It’s a Saturday busy night, in ED when a 31 yo male comes referring pain in the chin and next to the right ear after a trauma. He was out celebrating his birthday, slipped and fell on to his chin. 

Vital signs are normal, there aren’t wounds, he denies malocclusion, the palpation of the anterior ear elicite little pain, there’s not trismus. The tongue and the teeths are intact. 

I’m tired- he says- is my mandibula OK?

I will answer in a little while, says the doctor armed with a tongue depressor.

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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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