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Suspicions & Expectations

I always believe suspicion is the best forsight for any Emergency doctor.

Being logically suspicious is like having a strong likelihood diagnosis. Strong suspicion leads to a predictable expectation and better outcome for our patient

Case 1

15-year-old boy - falling off from the bicycle

Impact left lower chest and abdomen on bicycle handlebars

Damage to the helmet – bruising on left temple area ? LOC

10 mg IV Morphine by paramedics still C/O left lower chest and left upper abdominal pain

•HR 120/min BP 110/53 mmHg

•Sats 99% RA

•GCS 15

Suspicion Splenic injury

Rib fracture(s) with associated Haemo or pneumothorax

Positive findings

Hepato-Renal free fluid

Paracolic gutter free fluid

Pt. had a CT scan :

Positive findings

Splenic Trauma


We suspected splenic injury, bedside Ultrasound identified free fluid within 20mins of patient arrival. Did CT Abdomen on patient and confirmed splenic laceration. Patient transferred to Children's Hospital in a stable condition within 2 hours of being managed in our Emergency Department.

Case 2

82 year old man comes in c/o week of left hip and groin pain. He thinks it may have started whilst he was playing with his grandchildren about 1 week ago. Initially he was able to walk but over last 5 days walking has become increasing painful. Since morning he can barely put his left foot on the ground. He also has swelling of his left leg but no pain in the calf. His right leg is also swollen but less so. He thinks legs are swollen chronically after varicose vein surgery. Wife think may have a clot in the left leg ?

I have a poor suspicion to this story

? Maybe left calf DVT left groin DVT

He is tender in the left groin

Has mild swelling in the entire left leg

Bedside US by compression good saphenofemoral junction

Clot seen in superficial venous system in the left calf

Diagnosis Left leg pain due to superficial venous thrombosis

Hang on this does not make sense, not sure

Anyway let's admit him for analgesia and physio BUT let's get an xray of left hip done to exclude left NOF # (but there is no trauma and he has been walking on the left leg)


A very subtle left NOF cortical fracture !

CT Pelvis

Left NOF cortical fracture line clearly visible

Patient admitted under Orthopaedic Ward they decide patient can "weight bear as tolerated"

And this happens !


I missed diagnosed patient as superficial thrombophlebitis based on poor suspicion of DVT

But had a saving grace by 'just' requesting xrays. Took a long time. Orthopaedics throught we will just mobilise the patient and completed that fracture from a small cortical interruption to a nasty fracture NOF

Bedside US is a great tool if you have a strong clinical suspicion. It's is NOT a fishing rod to go looking for diagnosis. Sometimes history is not clear but that must dictate further formal investigations rather than exclusion and inclusion on bedside US

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