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Paucis Verbis: Strength of diagnostic tests for cholecystitis

MurphyYou have a 40 year-old man who presents to the ED for persistent right upper quadrant abdominal pain for 12 hours after eating a fatty meal. He has no fevers, nausea, flank pain, or dysuria. His physical exam shows no fever and only moderate tenderness in the RUQ without guarding. He has a Murphy’s sign which is improved after a total of 8 mg of IV morphine. His laboratory results, which include a WBC, liver function tests, lipase, and urinalysis, are normal.

Can you safely say that the patient doesn’t have cholecystitis? Can you discharge him for outpatient ultrasonography to assess for symptomatic cholelithiasis?

As bedside ultrasonography becomes more of a staple in Emergency Departments, it is easy to just perform the ultrasound yourself if such a patient presents. If you do not have an ED ultrasound available, however, you need to send this patient for a formal ultrasound because he is still very much at risk for cholecystitis despite having unremarkable lab tests and no fever.

JAMA published a meta-analysis of 17 studies on the test characteristics for cholecystitis. I found it odd that they defined a fever as temperature >35 Celsius. The best performing characteristic was a Murphy’s sign, although the positive likelihood ratio (LR) slightly crossed 1.0 (0.8-8.6).

PV Card: Diagnostic Testing for Cholecystitis


Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

  1. Trowbridge RL, Rutkowski NK, Shojania KG. Does This Patient Have Acute Cholecystitis? JAMA. 2003;289(1). doi: 10.1001/jama.289.1.80
By |2021-10-16T19:25:53-07:00Mar 18, 2011|ALiEM Cards, Gastrointestinal|
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Trick of the Trade: Topical anesthetic cream for cutaneous abscess drainage in children

AbscessDiagramAbscess drainage can be painful and time consuming in the ED. Can this article help? 1

Trick of the Trade

Apply a topical anesthetic cream on skin abscesses prior to incision and drainage (I and D).

In this press-released article in American Journal of Emergency Medicine, the authors found that application of a topical 4% lidocaine cream (LMX 4) was associated with spontaneous cutaneous abscess drainage in children.

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By |2019-07-10T21:29:20-07:00Mar 16, 2011|Infectious Disease, Pediatrics, Tricks of the Trade|
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Paucis Verbis: Right and posterior ECG leads

ECG EKG machine

A standard 12-lead ECG can be very telling for patients with chest pain or shortness of breath. A right ventricular (RV) and posterior wall infarct, however, can present very subtly. You can obtain special right-sided (V1R-V6R) and posterior leads (V7-V9), if you are concerned. What are the indications for obtaining right-sided and posterior ECG leads?


Go to the ALiEM Cards for more resources.

Addendum 3/11/11:

Right sided ECG leads (V1R-V6R) are positioned in a mirror image fashion from the standard 12-lead precordial leads.
Right-Sided
Posterior ECG leads (V7-V9) are applied by moving V4-V6 in the posterior positions.
ecg08_f9c

By |2021-10-16T19:28:52-07:00Mar 11, 2011|ALiEM Cards, ECG|
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Hot off the press: Clinical practice guideline for ketamine in the ED

Ketamine (475-10)

A 3 year old girl is brought into the ED with an abscess to her groin. Upon examination it is fluctuant and needs incision and drainage. Next door is a 5 year old boy, who fell off his bed and has an angulated radius fracture that needs reduction.

Hhhmmmm…how to manage these patients? Local anesthesia? Hematoma block? Nothing (aka brutacaine)? What about ketamine, that seems popular these days. IV? IM? With or without atropine? So many decisions!

Luckily you were surfing the internet one night and came across the 2011 clinical practice guideline on ketamine in the ED, which was just published.1

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By |2017-02-28T09:43:19-08:00Mar 1, 2011|Pediatrics, Tox & Medications|
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Paucis Verbis: Pneumonia risk stratification tools

Pneumonia RUL CXR

Pneumonia is a common cause for ED visits. How do you decide on whether the patient can be managed as an outpatient or inpatient? To supplement your clinical judgment, many clinicians use the Pneumonia Severity Index (PSI) score.

Have you heard of CURB-65, supported by the British Thoracic Society? What about SMART-COP, which is meant to help you predict if your patient will need Intensive Respiratory or Vasopressor Support (IRVS)?

PV Card: Risk Stratification Scoring Tools in Pneumonia


Go to the ALiEM Cards for more resources.

By |2021-10-16T19:31:04-07:00Feb 25, 2011|ALiEM Cards, Pulmonary|
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