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Likelihood Ratio (LR) in Emergency Medicine


Where is peritonitis?

Clinical Scenario

A 80 YO man with a history of hypertension presents to the ED complaining of abdominal pain. He felt well until 8 hours ago, when he developed diffuse abdominal pain. The patient is afebrile, tachicardic, BP is 180/100 his lungs are clear, ECG shows no changes suggestive of ischemia.  There is diffuse abdominal rigidity.

In another room there is a 22 yo girl with abdominal pain started two days before. She is febrile (38°C) and tachicardic, blood pressure is 120/80, her abdomen is soft. The cough test is positive, but rebound is negative.

In the 3rd room there is a 48 yo patient.  Come in -says the nurse- this abdomen is like a board.

Where is peritonitis?


Determining the presence or absence of peritonitis is a primary objective of the abdominal examination. All the methods alone are inaccurate. Thoracic inflammatory process adjacent to the diaphragm, a voluntary contraction of the abdominal wall in apprensive patients, a rough painful examination, may be misleading. But what is more interesting is that no test alone is useful in ruling out a diagnosis of peritonitis. Furthermore a gentle percussion is as inaccurate as the rebound test is, but it saves unnecessary pain.  


R McNamara
Approach to acute abdominal pain.
Emerg Med Clin N Am 2011 29 159-173

S McGee 
Abdominal pain and tenderness
Evidence based physical diagnosis Saunders Ed. 2007.

Ciro Paolillo


Run to the operation room!

Clinical Scenario

A 70 yo woman is brought to the ED by ambulance.
She’s suffering from vomit, lach of flatus and abdominal pain since 24 hours says the nurse. 
She’s pale, the abdomen shows a midline scar. There is diffused tenderness with rebound.
Abdomen US and X rays show abnormal distended loop of small bowel.

Ok, Ok I saw the images, there’s an occlusion says the surgeon at phone but, you know, I need a CT!

Are there CT findings that identify patients requiring a run to the operation room? 



My heart hates Christmas

Clinical Scenario

It’s 7 pm on Christmas day, a 32 yo woman refers palpitations since the morning. I was with my frends yesterday nigth, I think I had drank a bit too much. I Hate Christmas, it brings me down.
She’s awake, alert and oriented, her mood is low. Vital signs are normal,  EKG shows a sinus rhythm. 

 I’m sure it’s nothing but this damn holidays…



NO fever, NO bacteriaemia?

Clinical Scenario

A 80 yo nursing home resident woman  is brought to the ED by ambulance. 
“Hypothension, cough and a hystory of heart failure ”, refers the nurse. 
She looks pale and confused, her respiratory rate is 22, oxygen saturation on room air is 90%. Ear temperature is 36,5°C, BP  is 90/60 mmHg, HR is 95.
There’re pulmonary rales. Lactate are 4 mmol/dl.

Is it a low flow heart failure or is there and underline pneumonia? Does the absence of fever rule out bacteriaemia? 



Diagnosis of scaphoid fractures.
 Are plain radiographs reliable?

Clinical Scenario

It’s a busy wednesday morning in ED. 
A 18 yo guy presents with the right hand upraised and dressed. 
In the other hand he has a bundle of X ray.   
“About ten days ago, it was a Saturday night, I was with my new girl-friend. Hitting a punch bag as hard as possible I felt pain to my right wrist. My doctor ordered wrist X ray. It’s not broken, he says, but I’m very afraid, when I move the wrist  it pains me so much”.
On clinical examination there is snuff box tenderness, the axial loading maneuvre on the thumb is positive (see previous post). 
The emergency phisician takes an accurately look at the X rays. They are of high quality, the study had 4 views of the scaphoid, there’s no evidence of irregularity of cortex, the scaphoid fat pad seems normal.
“Repeat X-ray” orders the doctor….



Is a cold steak enough in black eye?

Clinical Scenario

A young guy comes to the ED after a car crash. While he was driving, the car in front of him stopped abruptly so they crashed. Fortunately speed was low and he does not report major trauma, but a black eye due to an impact towards the airbag. You promptly evaluate his sight and find no deficit, no diplopia, palpation does not show fracture steps or enphysema, skin sensation is preserved.

It’s nothing, just put a cold steak on it!

Would you really say this?



Is my hand broken?

Clinical Scenario

A 24 y/o guy presents in ED with the left hand upraised. 
“I fell off my bike yesterday – he says – I remember a serious impact with an outstreched palm.”
There aren’t wounds, he feels pain on the radial side of  left wrist, there is an anatomical snuffbox tenderness. The clamp sign is positive, but the resisted pronation maneuvre and the longitudinal compression test are negative.  

Is it broken? Asks worried the guy.