A 23-year-old man visits the emergency room. Upon awakening that morning, he noticed that his right hand was paralyzed.
- Age: 43
- Gender: Male
- Medical history: Blank
- Initial presentation: Missed a stairstep, unable to put pressure on right foot immediately after the event. Dorsal haematoma on right foot. Pain on palpation at metatarsal 1 to 4, axial pressure pain on the hallux.
How did you benefit from being raised abroad?
Living abroad, for any period of time, is a rewarding experience. By seeing other cultures and their way of life, you discover your own preferences. And of course you develop an understanding for other ways of life. As for my personal career, my degree from Johns Hopkins gave me an advantage and lead in Europe, probably more than I realized at the moment.
In lab reports often values of ASAT and ALAT are reported. Many do know it has something to do with the liver, but what is it actually? What does it reflect and how should the results be interpreted? A short explanation followed by two cases for self-assessment.
During the first day of my psychiatry internship an alarm went off. It was from one of the rooms on the closed psychiatric ward. Apparently, one of the patients was physically and verbally aggressive towards other patients and also to one of the nurses. It was decided to transfer the patient to one of the isolation rooms because he was refused to calm down and go back to his room to take his medication. I joined the group of nurses that were going to guide the patient to the isolation room. I asked if I could be of assistance, but as an intern there are moments where there is nothing one can do and this was one of them. Ultimately they managed to bring him to the isolation room, where he again refused to take his medication. Subsequently, I witnessed how the was given medication against his will; all I could do was not to interfere.
A few days the patient had calmed and was cooperative and was allowed to leave the isolation room. Not long after that, he approached me. He recognized me and told me that he noted that all the doctors where busy, yet he wondered whether I had time to talk. The following days we sat down to talk every time he was feeling upset. During one of our conversations he told me he felt relieved that someone took the time to listen to his frustrations. As an intern you always want to do as much as you can. It may appear that simply observing and listening is not ‘the real thing’. But during this internship I learned that it is a mistake to think this way. Sometimes this is all you can do, but at the same time it is more than enough.
In the not so distant past, plain radiography of the abdomen was one of the diagnostic tools in the management of patients with acute abdominal pain. It is quick, cheap and yields less radiation exposure than a CT-scan. However, multiple large studies showed that plain radiography of the abdomen has no additional value on top of clinical assessment in the evaluation of patients with acute abdominal pain (1-3). Furthermore, plain radiography gives the false reassurance of being able to exclude major pathology, for example, free air due to a bowel perforation. Moreover, if free air is seen on plain radiography mostly an additional CT-scan of the abdomen will be obtained to decide what type of operation has to be performed.
Multiple studies showed that the highest sensitivity and lowest radiation exposure, in patients with acute abdominal pain, can be achieved by first performing an abdominal ultrasound followed by, if the ultrasound is inconclusive, a CT scan (1). Therefore, in the Dutch guidelines for acute abdominal pain, there is no room for conventional imaging of the abdomen (4). Nevertheless, many doctors are still attributing great diagnostic value to plain radiography of the abdomen in the acute setting although scientific evidence is lacking. The future will show whether plain radiography in acute abdominal pain will definitely belong to ancient history.