Patient Physical Examination Findings Research Articles

Is Carpal Tunnel Release Necessary in High-Energy Distal Fractures of the Radius?

Purpose This study aimed to compare the clinical outcomes of patients who underwent volar plate osteosynthesis for high-energy distal radius fracture (DRFx) and carpal tunnel release (CTR) for acute or subacute carpal tunnel syndrome (CTS) with patients who did not undergo CTR. Methods This study is a retrospective evaluation of all high-energy DRFx treated with volar plate osteosynthesis in a regional hospital between January 2021 and January 2023. All adult patients (≥18 years) who underwent open reduction and internal fixation were included in the study after obtaining approval from the internal review board of our institution. Only patients who underwent plate osteosynthesis of the volar aspect through a modified Henry incision and patients who underwent CTR through a classic separate incision were included in the study. Clinical results includehand dynamometry, visual analog scale (VAS) scores, and physical examination findings of patients who underwent volar plate osteosynthesis because of high-energy DRFx and CTR due to CTS in the acute and subacute periods were retrospectively examined. Results Among the patients who underwent volar plate osteosynthesis because of high-energy DRFx, no statistically significant difference was detected between the hand grip strength and VAS scores of patients who underwent CTR because of acute CTS and subacute CTS at the sixth postoperative week (p>0.05). Conclusion Prophylactic CTR may be performed in the same session in selected cases, such as DRFx caused by a high-energy injury, to establish a scale for DRFx at a high risk of CTS and avoid delays in treatment. CTR for transient CTS detected in the subacute period during outpatient follow-up does not improve clinical outcomes.

Evaluation of the Epidemiological, Clinical and Radiological Features of Pneumonia Cases Caused by Mycoplasma pneumoniae in Childhood

The current study aimed to investigate the clinical, laboratory and radiological findings of the pneumonia cases in children that were confirmed as M.pneumoniae by polymerase chain reaction (PCR) testing and to reveal the factors that can be decisive in the diagnosis. Seventy-seven children were included in this study. The median age of the patients was 31 months (1 month-17 years 4 months). The 63.6% of the patients were younger than five years of age, 53.2% were girls and 46.8% were boys. During the eight-year research period, the frequency of M.pneumoniae in the patients hospitalized with the diagnosis of pneumonia was found to be 3.1%. The rate of M.pneumoniae as the underlying factor of pneumonia was found to be statistically significantly lower in patients aged 0-60 months compared to the patients aged 61-216 months. In patients with M.pneumoniae accompanied by viruses, the age group was more likely to between 0-60 months. The most common symptoms were cough (96.1%) and fever (74%). Physical examinations revealed that 70.1% of the patients had rales, 63.6% had tachypnea, 45.5% had oropharyngeal hyperaemia, 35.1% had subcostal-intercostal retraction, 31.2% had long expiration period, 26% had rhonchus, 24.7% had decrease in breath sounds, 15.6% had cervical lymphadenopathy, 13% had tachycardia, 3.9% had otitis media, 3.9% had tonsil hypertrophy and 2.6% had a maculopapular rash. The rate of hypoxemia was found to be 42.2%. When the physical examination findings of patients with only M.pneumoniae detected in multiplex PCR analysis and those with accompanying viruses in M.pneumoniae were compared, tachypnea, oropharyngeal hyperemia and decreased breath sounds were found to be statistically significantly higher in patients with M.pneumoniae only. Retraction was detected more frequently in patients with accompanying viruses. When the laboratory results of the patients were evaluated according to age, leukocytosis was detected in only 18.2% of the patients, while the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were found to be high in 75% and 85.7% of the patients, respectively. In the multiplex PCR analysis, the CRP values of the patients with only M.pneumoniae were found to be higher than the patients with accompanying viruses. M.pneumoniae was accompanied by viruses at the rate of 40.3%. The most common accompanying viruses were rhinovirus, adenovirus, bocavirus and metapneumovirus. The 55.8% of the patients had lobar-segmental consolidation, 46.8% had parahilar-peribronchial thickening, 18.2% had atelectasis, 11.7% had pleural effusion, 9.1% had increase in reticulonodular density, 6.5% had lymphadenopathy whereas no abnormality was observed in 5.2% of them. No diffuse interstitial involvement was recorded. The CRP value of the patients who had lobar segmental consolidation which was detected through chest X-rays were statistically higher than those without consolidation. In multiplex PCR analysis, the rate of parahilar-peribronchial thickening detected in chest X-ray findings was found to be higher in patients with M.pneumoniae accompanied by viruses compared to those with only M.pneumoniae. The rate of the patients who were given empirical antibiotics against atypical agents was 45.5%. The rate of empirically administered antibiotic treatment for atypical agents after being hospitalization was higher in patients diagnosed with only M.pneumoniae compared to patients with M.pneumoniae and viruses. One patient (1.3%) died. As there are no typical clinical, laboratory or radiological findings specific to M.pneumoniae pneumonia, all of the findings should be assessed as a whole to establish a diagnosis. Besides, for the detection of M.pneumoniae, diagnostic tests which are cost effective, with rapid results and are capable of distinguishing colonisation from active infection should be developed.

Efficacy of intravenous alpha lipoic acid in the treatment of neuropatic pain due to carpal tunnel syndrome.

<p>In this study, we analyzed the effect of oral and oral + intravenous Alpha-lipoic acid (ALA) treatment on pain level and physical examination findings in patients diagnosed with carpal tunnel syndrome (CTS).</p>. <p>A total of 115 patients patricipa&shy;ted in the study. Physiotherapy and wrist splint were first applied to all patients diag&shy;nosed with CTS in the study. 40 patients were treated with oral ALA after iv. ALA the&shy;rapy, 35 patients received only oral ALA treatment and 40 patients did not receive any medication. The patients were divided into 3 groups as those who received only splint treatment and physiotherapy, those who received oral ALA treatment, and those who received oral ALA treatment after iv. treat&shy;ment. All patients were assessed be&shy;fore the treatment, and at the 1st and 3rd months of the treatment. In clinical assessment, visual analog scale (VAS) forms were filled to define the pain severity, the Boston symptom severity scale (BSSS) and Boston functional status scale (BFDS) were filled for evaluating symptoms and functional status.&nbsp;</p>. <p>VAS, BSSS and BFDS scores of the patients who were treated with intravenous and then oral ALA were found to be significantly lower at the end of both the 1st and 3rd months compared to the patients who received only oral ALA or no medication (p=0.001; p&lt;0.001), (p=0.001; p&lt;0.001), (p=0.006; p&lt;0.001).</p>. <p>We think that iv. ALA is effective in the treatment of symptoms associated with CTS.</p> <p>&nbsp;</p>.

Temporal Trends and Prognosis of Physical Examination Findings in Patients With Acute Decompensated Heart Failure: The ARIC Study Community Surveillance.

Bedside evaluation of congestion is a mainstay of heart failure (HF) management. Whether detected physical examination signs have changed over time as obesity prevalence has increased in HF populations, or if the associated prognosis differs for HF with reduced or preserved ejection fraction (HFrEF or HFpEF) is uncertain. From 2005 to 2014, the ARIC study (Atherosclerosis Risk in Communities) conducted adjudicated hospital surveillance of acute decompensated HF. We analyzed trends in physical examination findings, imaging signs, and symptoms related to congestion, both over time and by obesity class, and associated 28-day mortality risks. Of 24 937 weighted hospitalizations for acute decompensated HF (mean age 75 years, 53% women, 32% Black), 47% had HFpEF. The prevalence of obesity increased from 2005 to 2014 for both HF types. With increasing obesity category, detected edema increased, while jugular venous distension decreased, and rales remained stable. Detected edema also increased over time, for both HF types. Associations between 28-day mortality and individual signs and symptoms of congestion were similar for HFpEF and HFrEF; however, the adjusted mortality risk with all 3 (edema, rales, and jugular venous distension) versus <3 physical examination findings was higher for patients with HFpEF (odds ratio, 2.41 [95% CI, 1.53-3.79]) than HFrEF (odds ratio, 1.30 [95% CI, 0.87-1.93]); P for interaction by HF type =0.02. In patients hospitalized with acute decompensated HF, detected physical examination findings differ both temporally and by obesity. Combined findings from the physical examination are more prognostic of 28-day mortality for patients with HFpEF than HFrEF.

Relationship between shoulder ultrasound findings and disease activity in patients with rheumatoid arthritis: A pilot study.

Objectives The aim of this study was to investigate whether shoulder ultrasound (US) findings were associated with disease activity and pain level in rheumatoid arthritis (RA) patients.Patients and methods Between April 2019 and November 2019, a total of 60 shoulders of 30 female patients with RA (mean age: 53.8±12.0 years; range, 30 to 65 years) were included. The patients were questioned about shoulder pain and their Disease Activity Score-28 (DAS28) was estimated. After clinical examination with shoulder impingement tests, both shoulders were evaluated by US.Results Of 60 shoulders examined by shoulder US, the most common shoulder pathology was supraspinatus tendinopathy (n=33, 55%). The prevalence of subdeltoid bursitis on US was significantly higher in the group with moderate disease activity, compared to the group with low disease activity (p<0.05). There were no significant differences in the physical examination findings of patients with low and moderate disease activity. In terms of US findings, subscapularis tendinopathy, glenohumeral joint and acromioclavicular joint degeneration, and subacromial bursitis were more common in shoulders with a history of pain, compared to non-painful shoulders.Conclusion Shoulder US may be useful for demonstrating shoulder involvement in patients with RA, independent of the presence of shoulder pain.

Physical Examination for the Detection of Pulmonary Hypertension: A Systematic Review.

We performed a systematic review to determine whether the physical examination can reliably assist in the diagnostic approach for patients suspected of having pulmonary hypertension (PH). Using dual extraction, two investigators independently searched PubMed, Ovid MEDLINE, Cochrane Library, and Embase for studies that compared physical examination findings with a right heart catheterization, from inception until July 10, 2021. We obtained data from four studies that evaluated physical examination findings in patients receiving a right heart catheterization to diagnose PH. Pooled diagnostic odds ratios (DOR) were calculated for right ventricular heave, a loud pulmonic component of the second heart sound (P2), jugular venous pressure (JVP) 3 cm above sternal angle, and a palpable P2.Three physical examination findings had DOR that supports the diagnosis of PH: the JVP > 3 cm above the sternal angle (5.90, 95% CI 2.57, 13.57), a loud P2 (2.91, 95% CI 1.38, 6.10), and a right ventricular heave (2.78, 95% CI 1.12, 6.89). The palpable P2 had a DOR less than one and was not able to be conclusive in diagnosing PH.Our systematic review found a small body of evidence supporting the use of physical examination tests in the diagnostic evaluation of pulmonary hypertension. The JVP > 3 cm above the sternal angle was the most accurate physical examination sign for the diagnosis of PH. Larger cohort studies using a combination of tests may shed more light on the role of the physical examination in the diagnosis and early detection of pulmonary hypertension.

HL-243: Unusual Primary Bone Marrow Hodgkin Lymphoma Presentation–Epidemiological Data from the University Clinical Center of Kosovo Between 2009–2020

Context Hodgkin lymphoma usually presents with the enlargement of peripheral lymph nodes and, very rarely, with isolated BM invasion. However, there are cases reported as primary BM HL. Objective Sharing an unusual case report of primary BM HL and its diagnostic and therapeutic outcomes. To evaluate the incidence, prevalence, age, sex, HL subtype, and treatment in Kosovo between the period of 2009–2020. Design A case report of a primary BM HL and an epidemiological analysis of HL cases in Kosovo for a period of 11 years. Case Report A 38-year-old female was admitted to our hospital because of fatigue, progressive fever, and pancytopenia for more than 1 month. Her medical history included prolonged metrorrhagia with no diagnosed cause. The patient was a non-smoker and did not take daily medications. No family history of malignant disorders was reported. The patient's physical examination findings were normal. Laboratory tests showed pancytopenia, high CRP, negative results for SARS-CoV-2 and HIV, and TM was negative. A positive ANA and a high C3 led us to assess her rheumatological picture, but with a negative outcome, she did not fulfill the criteria for LES. A CT revealed a chronic fibrotic consolidation in the right lung, with no evidence of infection or inflammation. After no significant findings, we decided to perform a BMB, which resulted in HL-MC. Results We treated our patient with the ABVD protocol, and her physical and laboratory findings started to improve within the first round of chemo. After six rounds of ABVD, our patient's condition was improved. Our patient is, for the moment, in hematological remission. Conclusions There were a total of 127 patients analyzed, of which 37.80% were females, and 62.20% were males. The average age at the time of submission was 50 years. First-line treatment was the ABVD protocol, and it showed a very effective outcome, with a CR of 67.7%. Second-line therapies were the BEACOOP and MINE protocols. The patient with primary BM HL had a very good outcome from the classical protocol of treatment with ABVD, after which she had an HR, and we are looking forward to a CR in the near future, confirmed by a BMB.

Predictors of critical illness and mortality based on symptoms and initial physical examination for patients with SARS-CoV-2: A retrospective cohort study

IntroductionAn unidentified cluster of pneumonia was identified in Wuhan city of China in the last week of December 2019, named Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-COV-2). The current study explored the predictors associated with critical illness and mortality based on symptoms at the time of admission and initial physical examination findings in patients with SARS-CoV-2. Material and methodsA total of 249 records of laboratory-confirmed SARS-COV-2 patients were analyzed. Demographic profile and findings of initial physical examination were collected and analyzed. Bivariate logistic and multivariable stepwise forward regression analysis was used to identify the predictors of critical illness and mortality. ResultsA total of 249 records of SARS-COV-2 patients were retrospectively studied, of whom 66 (26.5%) developed a critical illness, and 58 (23.29%) died. The mean age of patients was 45.15 (16.34) years; 171 (68.71%) were men. From 27 potential predictors for developing a critical illness, 15 were reported independent predictors for critical illness, and 13 were for increased risk of mortality. Stepwise forward regression reported dyspnea as a single strongest predictor (OR, 5.800, 95% CI-2.724−12.346; p = 0.001, R2 = 0.272) to develop critical illness. Likewise, the respiratory rate was alone reported as a strong predictor (OR, 1.381, 95% CI- 1.251−1.525; p = 0.000, R2 = 0.329) for mortality. ConclusionsCoronavirus disease is a new challenge to the medical fraternity, leading to significant morbidity and mortality. Knowledge of potential risk factors could help clinicians assess patients' risk with unfavourable outcomes and improve hospitalization decisions in the early stage.

Physical Examination Findings in Patients with Protracted Concussion and the Impact of an Integrative Concussion Rehabilitation Protocol

Purpose: To describe physical examination (PE) findings of individuals with protracted concussion recovery and evaluate an integrated primitive reflex (PR) disinhibition, vision, and vestibular rehabilitation intervention. Method: Retrospective study of 82 patients with protracted concussion (60.98% female) who received ≥ 2 phases of treatment. Following a baseline PE, patients completed the Post-Concussion Symptom Survey (PCSS), Activities-Based Balance Confidence Questionnaire (ABC), Dizziness Handicap Index (DHI), and Acquired Traumatic Brain Injury (aTBI) Vision Questionnaire. A subset of patients (Group 1), completed a final PE and second questionnaire administration. Descriptive statistics characterized the sample. T-tests and Wilcoxon rank sum tests compared characteristics of Group 1 vs Group 2. Wilcoxon sign rank tests assessed changes in patient-reported outcomes. Results: Patients in Groups 1 (median age=23.5) and 2 (median age=17.5) were similar regarding demographic and PE findings. Statistically and clinically significant improvements were seen for Group 1: PCSS (-21 points, MCID 6.8), DHI (-27 points, MDC 17.8, MCID 19), ABC (+ 8.5 points, MDC 9)and aTBI Vision Questionnaire (-16.5 points). Conclusion: Patients with protracted concussion recovery can benefit from a multitude of interventions ranging from orthopedic to vision and vestibular interventions in order to address objective deficits and subjective complaints such as headache, dizziness, or blurry vision following a concussion. Patients who completed the full intervention demonstrated clinically significant improvements in function, including return to school/work and recreational activities. These data suggest there is a potential positive benefit to a structured, integrative concussion rehabilitation approach for individuals with protracted concussion recovery.

A Bone or a Fracture: Subtibiale

A 60- year-old female patient admitted the emergency department (ED) because of falling from high. She was suffering right ankle pain. The patient's physical examination findings were tenderness on right ankle. Right ankle and tibia-fibula x-ray graph were performed. X-ray graph revealed that a small bone which is one of the sesamoid bone called os subtibiale, were localized behind the fibulae. If it is not evaluated carefully, this sesamoid bone can be misdiagnosed as fracture easily. Recognition of sesamoid bones and their location are important to protect patients from unnecessary and improper interventions.

Investigating the Biochemical Parameters Derangement and Physical Examination Findings in Patients with Non-Alcoholic Fatty Liver Disease

Investigating the Biochemical Parameters Derangement and Physical Examination Findings in Patients with Non-Alcoholic Fatty Liver Disease

The Relationship between Polyneuropathy and Cognitive Functions in Type 2 Diabetes Mellitus Patients.

Objectives:Type 2 Diabetes Mellitus (DM) is a risk factor for mild cognitive impairment (MCI), Alzheimer’s disease and vascular dementia. However, it is not known which pathophysiological mechanisms lead to impairment in cognitive functions in Type 2 DM. This study aims to compare the cognitive functions of diabetic patients with and without polyneuropathy using standardized Mini-Mental Test (MMSE) and the Montreal Cognitive Assessment Scale (MoCA) and to assess whether the presence of polyneuropathy is a predictive factor for the development of cognitive impairment.Methods:Patients with DM who underwent our EMG laboratory for polyneuropathy between January 2014 and January 2015 were included in this study. Patients who underwent electrophysiological examinations were evaluated for polyneuropathy. Patients with polyneuropathy were classified as a patient group and other patients as a control group. In all cases, MMSE and MoCA were administered. The demographic data and educational status of the patients were recorded. Hypertension, coronary artery disease, smoking and alcohol use were questioned. Their complaints, duration of illness and the treatment they were receiving were questioned. Glycosylated hemoglobin (HBA1C) values in the last three months and physical examination findings of patients were recorded. Patients with and without polyneuropathy were compared with statistical methods.Results:Polyneuropathy was detected in 34 (42%) of the 81 patients who participated in our study. The age, disease duration and HBA1C levels were statistically higher in the polyneuropathy group than in the control group (p=0.024, p=0.000, p=0.016). However, there was no statistically significant difference between MMSE and MoCA scores of these groups. In both groups, there were no patients scoring below the MMSE cut-off value of 24. Seventeen of the 34 patients (50%) in the polyneuropathic group and 19 (40,4%) of the 47 patients in the control group had scores below the MoCA cut-off value 21. However, there was no statistically significant difference between the two groups. We also found that the mean MoCA value of all DM patients was 21, which was the MoCA cut-off value. Also, factors affecting cognitive functions in all Type 2 DM patients were evaluated by logistic regression analysis, and it was found that duration of education was an independent factor affecting cognitive impairment (OR=8.167; p=0.001).Conclusion:In our study, we did not observe significant differences between MMSE and MoCA scores of Type 2 DM patients with and without polyneuropathy. However, the cross-sectional nature of our study makes it impossible to comment on this issue. To clarify whether the presence of polyneuropathy is a predictive factor in the development of cognitive impairment in Type 2 DM, there is a need for a larger sample group and long-term follow-up studies. It has also been shown that patients with Type 2 DM may have low scores according to the MOBID cut-off value even though peripheral neurologic involvement findings are not observed. In the Type 2 DM population, it has also been shown that MoCA may be affected by education level.

Multidisciplinary Alternatives to CPAP Program for CPAP-Intolerant Patients.

Continuous positive airway pressure (CPAP) intolerance remains a persistent problem for many obstructive sleep apnea patients. Clinicians and researchers continue to search for other effective treatment modalities given the well-documented sequelae associated with untreated obstructive sleep apnea. A multidisciplinary "Alternatives to CPAP program" (ALT) can facilitate systematic evaluation of non-CPAP therapies appropriate for an individual patient. We review successful strategies and barriers encountered during implementation of an ALT at our institution. Creation of similar programs in private practice and academic settings can help medical, dental, and surgical sleep medicine specialists coordinate evaluation and treatment of CPAP-intolerant patients.

Correlation of Cord Signal Change With Physical Examination Findings in Patients With Cervical Myelopathy

Retrospective case series. To determine whether cord signal change (CSC) visualized on magnetic resonance imaging (MRI) correlates with level-specific physical examination findings as well as other signs of cervical myelopathy. Although CSC is often used as a marker for severe cervical spine pathology, it is not known whether CSC detected on MRI actually translates clinically into level-specific findings detected on physical examination. A consecutive series of patients with CSC evident on MRI operated on by a single surgeon from 2010 to 2012 were retrospectively analyzed. Patients' preoperative reflex examination (biceps, brachioradialis, and triceps) including abnormal reflexes (Hoffman sign, inverted radial reflex, clonus, and Babinski) were recorded. Patients were deemed to have an examination consistent with the level of CSC if they had normal reflexes cranial to the level of CSC, were hypo-reflexic at the affected level, and hyper-reflexic caudal to the level of CSC. Forty-three patients with CSC were identified during the study period (Table 1). Isolated T2 CSC was present in 35 patients, and concomitant T1 and T2 CSC was present in 8 patients. Interestingly, the reflex examination correlated poorly with the cranio-caudad level of CSC, with only 11 of 43 patients (26%) having a concordant examination. In patients with CSC, 16% had clonus, 67% had Hoffman sign, 44% had Romberg sign, and 60% had a gait abnormality. CSC visualized on MRI correlates poorly with the upper extremity reflex examination in patients with cervical myelopathy. Of the pathological reflexes, Hoffman sign has the strongest association with CSC, but still was only positive in 67% of cases. More sensitive clinical measures need to be developed to more accurately associate CSC detected on MRI to the clinical severity of cervical spondylotic myelopathy.

Retrospective Analysis of Nasal Fractures in the Emergency Clinic

Objective: The aim of this study is to analyze the demographic and diagnostic characteristics of patients presenting to the emergency clinic with nasal trauma. Material and Methods: Data analysis was performed with imaging tests on the files of 77 patients presented to the emergency clinic between 2012 and 2013. Results: In order of prevalence, nasal fractures were caused by falls from heights, violence, trauma, sports injuries and traffic accidents. Physical examination findings in patients with nasal fracture were sensitivity, nose swelling, nasal mucosal hemorrhage and septal deviation. Fracture was also determined at physical examination in 26 (86.6%) of the 30 patients with fracture detected at tomography. In the analysis, approximately 26% were multiple depressed fractures, while linear fracture along a single line was determined in 31%, with fissure-type fracture in the remaining 43%. Pathologies such as septal edema or hemorrhage were present in 30 of the 77 patients, while the septum was mobile and dislocated in approximately 16 of these patients (33.7%). Conclusion: Falls from heights were the most common cause in patients with nasal fracture, and although the most common imaging technique employed was x-ray, tomography provided more detailed information concerning rhinorrhea, smell perception disorders, maxillofacial traumas and multiple nasal fractures. (JAEM 2014; 13: 139-42)

AB0977 Biomechanical factors and physical examination findings in osteoarthritis of the knee: Associations with tissue abnormalities assessed by conventional radiography and by high resolution magnetic resonance imaging

BackgroundAlthough biomechanical factors of the knee joint like muscle strength, proprioceptive accuracy and laxity play an important role in knee osteoarthritis (OA), only limited evidence exists on associations with specific...

Underdiagnosis of anaphylaxis in the emergency department: misdiagnosed or miscoded?

To distinguish allergic reactions and anaphylaxis, and to highlight the importance of anaphylaxis. Case series. Adult emergency department of the medical faculty of Hacettepe University, Ankara, Turkey. Adults admitted to the emergency department between 1 May 2005 and 30 April 2010 with allergic diseases considered to be anaphylaxis or anaphylactic reactions. Patient age, gender, possible cause(s) of allergy, organ involvement, treatment, and physical examination findings. Although recorded physical examination findings of patients were consistent with anaphylaxis, 88 patients were not diagnosed as having this condition. All patients in this study group were evaluated in the emergency department facility and did not consult or were not referred to any other department or specialist. In all, 79 (90%) of them were discharged in the first 12 hours, 5 (6%) after 12 to 24 hours, and 4 (5%) after 24 hours. None of these patients died. Emergency physicians should be better able to recognise the clinical features of anaphylaxis, so as to treat the episode promptly and appropriately. Delay in diagnoses could lead to incomplete treatment and even be fatal.

Analysis of Patients Presenting to the Emergency Department with Acute Abdominal Pain

Objective: Acute abdominal pain is a common cause of admission to the emergency department. Differential diagnosis of abdominal pain is not easy for the emergency physician. In this study, the results of physical examination, blood biochemical analysis and radiological imaging in patients presenting to the emergency department with abdominal pain were evaluated. These findings were compared with the literature. Material and Methods: This study was designed as a cross-sectional descriptive study. One hundred and sixty-six patients were included. Patient physical examination findings, amylase, D-dimer and leukocyte values and radiological and surgical findings were evaluated. Results: All patients had abdominal physical examination findings. Seventy-two (43.4%) patients had only abdominal sensitivity, 33 (28%) patients showed gall bladder pathology by ultrasound and no pathology was found in 36 patients (30.7%). A mass was determined in three (8.1%) of 37 (22.3%) patients, appendicitis in four (10.8%), gall bladder pathology in three (8.1%), ileus-volvulus in four (10.8%) and mesenteric ischemia in six (16.2%) patients who were examined by abdominal tomography. Conclusion: Despite advances in imaging and laboratory techniques, the great majority of cases with acute abdominal pain cannot be definitively diagnosed, as in this study, and are evaluated as non-specific abdominal pain. The fact that selected cases are transferred to the center where the investigation is performed may create a discrepancy with the literature. In this study, the frequency of gall duct-related diseases was higher than in the literature and cases of acute appendicitis were much less frequent. (JAEM 2012; 11: 212-5)

The predictive value of physical examination findings in patients with suspected acute heart failure syndrome

It can be difficult to differentiate acute heart failure syndrome (AHFS) from other causes of acute dyspnea, especially when patients present in extremis. The objective of the study was to determine the predictive value of physical examination findings for pulmonary edema and elevated B-type natriuretic peptide (BNP) levels in patients with suspected AHFS. This was a secondary analysis of a previously reported prospective study of jugular vein ultrasonography in patients with suspected AHFS. Charts were reviewed for physical examination findings, which were then compared to pulmonary edema on chest radiography (CXR) read by radiologists blinded to clinical information and BNP levels measured at presentation. The predictive value of every sign and combination of signs for pulmonary edema on CXR or an elevated BNP was poor. Since physical examination findings alone are not predictive of pulmonary edema or an elevated BNP, clinicians should have a low threshold for using CXR or BNP in clinical evaluation. This brief research report suggests that no physical examination finding or constellation of findings can be used to reliably predict pulmonary edema or an elevated BNP in patients with suspected AHFS.

Acute and Chronic Mesenteric Ischemia Due to Superior Mesenteric Artery Embolus

Purpose: Introduction: The clinical presentation of mesenteric ischemia is dependent on the underlying etiology, with acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI) presenting differently. The classic clinical picture of AMI involves severe abdominal pain with a paucity of physical examination findings in patients with cardiac risk factors. In contrast, CMI typically causes postprandial abdominal pain, weight loss and sitophobia. We describe a rare case of AMI and CMI due to superior mesenteric artery (SMA) embolus in a patient with atrial fibrillation. Case Presentation: A 63-year-old female presented with sudden onset of severe abdominal pain for 2 days. The pain was associated with nausea and vomiting. Her medical history was significant for atrial fibrillation (AF) on anticoagulation. Her vital signs were T 101.1°F, BP 158/90 mmHg, HR 109 beats/min, RR 28 breaths/min, and SpO2 97% on ambient air. Her heart sounds revealed a rapid, irregular rhythm. The abdomen was soft and mildly tender to deep palpation in the left lower quadrant. Laboratory studies were unremarkable except for a WBC of 10.900/μL with 79% neutrophils. Abdominal radiograph and CT demonstrated distended proximal loops of bowel. Subsequent selective arteriography showed an abrupt cutoff of the proximal SMA distal to the first left jejunal branch consistent with embolism. Since there were no definitive signs of bowel necrosis, she was treated conservatively, including anticoagulation with heparin/warfarin. Three months later, however, she presented with chronic left quadrant pain associated with weight loss. Abdominal CT revealed thickened loops of small bowel in the left abdomen with haziness of the associated mesentery, representing chronic ischemia from SMA embolus. With adequate analgesics and therapeutic anticoagulation, her symptoms improved. Discussion: Although AMI and CMI present differently in general, both can progress to bowel infarction rapidly if untreated. Our case is of interest in that CMI developed after AMI and was managed without surgical intervention. Treatment of mesenteric ischemia is dependent upon the type and degree of ischemia, but any patient with peritoneal signs should be operated without delay. Patients with minor emboli, limited to SMA branches or to the SMA distal to ileocolic artery, as was shown in our case, may be managed conservatively with volume resuscitation and anticoagulants. Mesenteric ischemia is a relatively uncommon cause of abdominal pain, but one with a high mortality rate. Its prompt recognition and aggressive treatment can prevent bowel infarction. Therefore, in the proper clinical settings, it is crucial to maintain a high index of suspicion.