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Disease presentations

Discussion in 'Emergency Medicine' started by AmoryBlaine, Mar 7, 2007.

  1. AmoryBlaine

    AmoryBlaine the last tycoon

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    I had a thought the other day when I was walking out of the hospital, although I am most of the way through my 3rd year I have almost never seen a pt who was a "classic presentation."

    If you read Cope you would be left with the impression that the qualities of pain, locations of referred pain, timing of onset etc will give you the correct dx. But I consistently read journal articles that describe the wild variation in presentation of even simple cases, there was that recent paper in AEM about appendicitis is peds that basically concluded that there was no "classic picture."

    So the question for the higher-ups here is do you ever trust the story? I mean, a 55y/o obese dude complaining of RUQ pain that sounds clearly biliary with a +Murphy's aren't you always going to get the amylase/lipase and ROMI?

    Is this a) the philosophy of EM, b) the fault of the attorneys, or c) the result of "getting fooled" by pts presenting in variable ways?
     
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  3. BADMD

    Physician

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    I can't tell you what other people do, but what I do is a combination of the above. I'm going to get a lipase (more specific than amylase) due to the association between pancreatitis and cholecystitis anyway. But I'm going to get an ECG and a tropinin and give an aspirin, in addition to the RUQ U/S. It isn't so much cover the ass as I've been there too many times when persuing one diagnosis only to end up without any evidence for that diagnosis and then having to back up and redo and rethink things.

    What I do now is build a case for each and against each. So, if this guy is pain free in 2 hours, has stones on his U/S, an unchanged ECG, a non-detectable high sens tropinin, and bumps in his LFTs, I'm pretty sure it is billiary and not cardiac as I have evidence for one and against the other.

    Now, if I don't see stones, labs are normal and I see some T wave inversions, the guy is going to get a full rule out, even it is billiary. In this case, I don't have evidence for biliary disease and some possible evidence (although weak) for a cardiac etiology.

    I once had a presentation that was exactly like this and it turned out to be a right lower lobe infiltrate. She had no cough or difficulty breathing. If I hadn't gotten a chest xray, I would have missed it.

    For all patients you have to build a list of "bad things" that you need to consider and then rule them out. Some of these things can be ruled out by history and physical exam, for others you want some reassuring evidence, based on the presentation. The art is deciding when physical exam and a good history is enough.
     
  4. BKN

    BKN Senior Member

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    Remember that "classic" presentations were described by "classic" physicians working generally between 1850 and 1920. They had limited diagnostic tools. They could spin a crit, use a hemacytometer to do a white count, do a Schilling count (differential) and a gram stain. Their imaging consisted of none until the 1890s and plain films with or without barium. The way they knew they were right was at autopsy or operation.

    Not surprisingly, they probably got the obvious stand outs and these became the "classic" descriptions. Usually, however the classic description is not the common one. Think of migraine classic vs common as the perfect example.

    As to your specific question, I don't have enough info. For some 55 yo Ms I do the lipase and romi, others perhaps not. It's called judgement and it takes a while to get good at it (>10 years?)

    I absolutely recommend memorization of Cope. I use less diagnostics then I used to, but a CT in hand is worth all of the clinical judgement and lab together and then some. :D

    Am J Emerg Med. 2005 Oct;23(6):709-17.Related Articles, Links
    [​IMG] [​IMG] [​IMG]
    [SIZE=+1]Derivation of a clinical guideline for the assessment of nonspecific abdominal pain: the Guideline for Abdominal Pain in the ED Setting (GAPEDS) Phase 1 Study.[/SIZE]

    Gerhardt RT, Nelson BK, Keenan S, Kernan L, MacKersie A, Lane MS.

    Department of Emergency Medicine, Brooke Army Medical Center/San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX 78234, USA. [email protected]

    OBJECTIVE: The purpose of this study was to identify a clinical guideline for the evaluation of nonspecific abdominal pain (NSAP) using history, physical examination, laboratory analysis, acute abdominal series (AAS) radiographs, and nonenhanced helical computed tomography (NHCT) clinical predictor variables (CPVs). SETTING: The setting of this study was at an urban emergency department (ED) with 70,000 yearly visits. METHODS: This is an institutional review board-approved, prospective, observational study. The primary outcome variable was urgent intervention (UI), defined as a diagnosis requiring surgical or medical treatment to prevent death or major morbidity. Subjects underwent prompted history, physical, laboratory studies, AAS, and NHCT and were followed up to 6 months for ultimate diagnosis and outcome. CPVs were subjected to classification and regression tree analysis. RESULTS: One hundred sixty-five subjects were analyzed. Thirteen percent of subjects required UI within 24 hours of presentation; an additional 34% underwent elective interventions that mitigated morbidity or mortality. Four guideline models were generated. Model 1 consisted of history and physical, with a sensitivity of 25%, a specificity of 92%, a positive likelihood ratio of 3.17, and a negative likelihood ratio of 0.81. Model 2 consisted of model 1 with laboratory, with a sensitivity of 39%, a specificity of 88%, a positive likelihood ratio of 3.25, and a negative likelihood ratio of 0.69. Model 3 consisted of model 2 with AAS, with a sensitivity of 56%, a specificity of 81%, a positive likelihood ratio of 2.94, and a negative likelihood ratio of 0.54. Model 4 comprised all inputs, including NHCT, with a sensitivity of 92%, a specificity of 90%, a positive likelihood ratio of 9.2, and a negative likelihood ratio of 0.089. NHCT was the single most accurate CPV for UI. CONCLUSIONS: No clinical guideline was identified exclusive of NHCT that possessed adequate sensitivity for exclusion of UI. NHCT is a rational choice for decision support in the evaluation of NSAP and is likely the single most useful diagnostic adjunct available to augment the clinical evaluation.

    Publication Types:
    MeSH Terms:
    PMID: 16182976 [PubMed - indexed for MEDLINE]
     
  5. AmoryBlaine

    AmoryBlaine the last tycoon

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    Thanks for the reply. I realized on my way to work this AM that you'd have to check am/lip in suspected biliary dz anyway.

    I think it was obvious but my question was more about philosophy than that one example.
     
  6. 12R34Y

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    I've worked in 3 different ED's as a resident now and nobody there (staff, seniors, me) orders amylase AND lipase for biliary/r/o pancreatitis.

    we get lipase (more specific and as sensitive as amylase).

    are you routinely ordering amylase? if so why?

    later
     

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