Don't Miss That POOP (Pain Out of Proportion)

Introduction

  • Speaker Introduction

    • Vuket Tran, Family Doctor and Emergency Medicine Specialist

    • Currently practices Emergency Medicine and Long-Term Care (LTC), previously practiced Family Medicine.

    • Expressed gratitude to the audience for attending the talk.

Topic Overview

  • Presentation Title: "Don't Miss That Poop: Pain Out of Proportion"

  • Relevance of the topic in various medical fields:

    • Emergency Medicine

    • Acute Care Medicine

    • Urgent Care Medicine

    • Hospitalist Medicine

    • Family Medicine

Disclosure

  • Previous role as an adviser and chief medical officer for a medical cannabis company, which is no longer operational.

Learning Objectives

  • Describe physical examinations, investigations, and pitfalls related to abdominal and extremity "poops".

  • Evaluate and treat abdominal and extremity conditions associated with significant pain.

  • Utilize QR codes for audience interaction and response.

Key Messages

  • Message #1: "Please do not poo poo a poop.”

    • Importance of acknowledging patient symptoms, especially severe pain.

  • Message #2: If a patient is in pain, it is your responsibility to investigate thoroughly.

Diagnostic Philosophy

  • Quote from Dr. Gandhi:

    • "A correct diagnosis is three-fourths of the remedy."

    • Emphasis on the significance of accurate diagnosis to avoid fatal consequences.

  • Quote from Dr. Michael Dabacki:

    • "No physician can diagnose a condition he never thinks about."

    • Reminder for healthcare providers to broaden their differential diagnoses.

Types of "Poops"

  • Pain Out of Proportion:

    • Defined as patients presenting with severe pain despite unremarkable physical exams.

    • Common thought: assumption of drug-seeking behavior.

Abdominal Poops

  • Definition: When pain is severe but physical examination yields no findings.

  • Case Example:

    • A 56-year-old male presents with:

    • Sharp left flank pain radiating to the left scrotum.

    • Vital signs: high pulse (99), elevated respiratory rate, normal blood pressure.

    • Urinalysis shows traces of blood.

  • Initial Thoughts: Common diagnosis consideration is kidney stones or renal colic.

Management Choices

  1. Provide analgesia and discharge.

  2. Analgesia plus ultrasound.

  3. Analgesia plus CT scan.

  4. Point Of Care Ultrasound (POCUS).

  • Preferred Approach: Utilize POCUS as a rapid diagnostic tool to rule out crucial conditions without over-reliance on CT scans.

Diagnosis Awareness

  • Misdiagnosis Risks:

    • Ruptured Abdominal Aortic Aneurysm (AAA) mimics renal colic pain.

    • Classic triad for AAA: back pain, pulsatile mass, and hypotension (less than 50% common).

  • Risk Factors: Older age, male gender, Caucasian, hypertension, family history, smoking, and rapid aneurysm expansion (greater than 5.5 cm).

Example Symptoms of AAA

  • Potential Symptoms:

    • Abdominal pain, back pain, or syncope.

    • Patients may present asymptomatically or with nonspecific symptoms.

Quick Diagnosis Strategies

  • If AAA is suspected:

    • Quick examination: use POCUS to check aorta size (<3 cm = no aneurysm).

    • If found >3 cm, urgent consultation with a vascular surgeon is critical.

Case Example: Ischemic Bowel

  • Patient: Mrs. Smith, exhibiting atypical severe pain behavior due to dementia, resulting in delayed diagnosis.

  • Conditions to Note:

    • Types of ischemic bowel:

    1. Artery embolus.

    2. Artery thrombosis.

    3. Mesenteric vein thrombosis.

    4. Non-occlusive mesenteric ischemia (NOMI) in patients with heart or renal failure.

  • Critical Signs: Pain out of proportion without clear physical examination findings.

  • Mortality Rates: High if diagnosed late (up to 90%).

Extremity Poops

  • Common Causes:

    • Necrotizing fasciitis vs. compartment syndrome.

  • Missed Diagnoses: Due to reliance on traditional clincial signs (cold leg, lack of pulse).

Key Diagnostic Indicators for Compartment Syndrome

  • Classic Symptoms:

    • Severe pain, tightness, and might feel pain on passive movement.

  • Timely Intervention: Fasciotomy required within 6 hours of symptom onset to avoid permanent damage.

Skin Poops (Necrotizing Fasciitis)

  • Pathogens: Group A Streptococcus, invasive Staph, Vibrio, etc.

  • Symptoms:

    • Presents as cellulitis but with pain out of proportion and rapid progression.

  • Clinical Indicators:

    • High degree of suspicion is mandatory.

Hydrofluoric Acid (HF) Burns

  • Overview: Burns from HF are particularly dangerous due to potential hypocalcemia leading to fatality.

  • Signs: Intense pain, often delayed recognition due to dilution in home use.

  • Management: Immediate treatment includes removing contaminated clothing and administering calcium.

Concluding Remarks

  • Importance of thorough clinical evaluation:

    • Pain out of proportion is a significant clinical indicator not to be disregarded.

  • Acknowledging cognitive traps and maintaining a broad differential diagnosis are essential.

  • Continuous education and practice to enhance diagnostic skills in emergency settings.

Call to Action

  • Recommendations:

    • Emphasize teaching and learning about significant clinical indicators.

    • Encourage study and practical application of POCUS and awareness of common "poops" in emergency medicine environments.

  • Urgent care practitioners should maintain a