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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Is CRP useful alone to support the hypotesis of a bacteremia?

Clinical Scenario

It’s a very cold February, but ED is very hot in every sense of the word. 

A 22 y/o student refers stomach pain, chills, fever and diffuse muscolar pain. He has fever (38° C) there is a mild diffuse abdominal pain. 

The CRP value is 30 mg/L. 

Are there flu symptoms, or it is a bacteremia?

Can we use the CRP test for change our clinical suspicion? 

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Malaria or just fever?

Clinical Scenario

A 35 y/o man is brought to the ED by friends and left there alone, he has high fever, he is from Ghana and he has just arrived, he speaks english not so well and he is confused and agitated, so anamnesis is very difficult and you catch a only word “malaria”, you also know that africans often calls malaria every fever, but …

Clinical examination is normal except for the agitation state, but fever is very high (40,5°C), he has not headhache, no cough, no abdominal pain. It is night and microbiologist is not available for malaria microscopy test and you decide to perform, for the first time in your life, the rapid test…it is negative…

Can you trust it or the patient?

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Is chest X ray necessary to rule out PNX after thoracic maneuvers?

Clinical Scenario

It’s a busy day in ED this morning. 

The first patient refers dyspnoea, he has an advanced pulmonary neoplasia, ultrasound and chest x-ray confirm that the left zone is occupated by a pleural effusion. The thoracentesis removes about 1.5 liter of fluid, the patient breathes easily.

The second patient is 65 yo, he has pneumonia, he is septic, it’s impossible to find a vein, the right internal jugular vein is identified by ultrasound and the catheterization is performed without any problem.   

Is it necessary in this cases to perform a chest  X-ray to rule out a PNX?

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Useless ECG?

Clinical Scenario

A 67 y/o man arrives to the ED by ambulance because of precordial pain since half an hour, during the transport, paramedics perform an ECG that shows a left bundle branch block (LBBB), that patient refers in his history.

They find it unuseful and so they do not transmit it to the cardiologist, is it correct?

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Is it broken?

Clinical Scenario

Anthony, a 15 y/o student, slipped and fell while playng soccer. The next morning he refers continue pain on the right elbow. “Is it broken?” ask Anthony and his father at the triage desktop?

There is pain and edema near the elbow, no radial pulse deficit, he can fully extend and flex the articulation, there aren’t problem about prono-supination.

The doctor smiles and reassures Anthony and his father, “it’s not broken, RICE is enough!!!”.    

  

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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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