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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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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