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News: Take the EMN POOP Test

Coleman, Matthew

doi: 10.1097/01.EEM.0000427362.11908.a5

It's simple: pain out of proportion (POOP) kills.

“It seems easy enough, but when it comes to clinical practice, how often do we hear our residents say: 'He is complaining of belly pain and sleeping. I'm not worried about it,'” said Mimi Lu, MD, a clinical assistant professor at the University of Maryland School of Medicine.

Emergency physicians are inundated with information, but a physician should respond quickly when a patient presents with POOP and a “condition that makes us think there is something else that should be going on,” Dr. Lu said. “We work in an environment where time is of the essence. If we can think of these conditions early, we will change lives.”

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Test Your POOP Smarts

OK, EPs, here is your chance to test your POOP knowledge. We provide three cases that Dr. Lu posed to attendees at the ACEP Scientific Assembly in Denver last fall. These presentations combined with pain out of proportion should trigger the immediate thought of an illness. Good luck!

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Patient 1

Ms. Rose is a 92-year-old woman with hypertension and diabetes. She presents with severe abdominal pain, chest pain, mild confusion, and irregular tachycardia. She has a lot of comorbidities. She was initially admitted, given a host of diagnoses (chronic atrial fibrillation, constipation, urinary tract infection), and discharged home.

She comes back a month after her discharge with severe abdominal pain. No chest pain. No vomiting. No fever. Same thing. She looks uncomfortable, but her belly is unimpressive. You get labs. She has a huge white count.

Bottom Line: Severe abdominal pain (POOP) + benign exam = ?

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Patient 2

Mr. Sky is a 57-year-old diabetic who has had rectal pain for two days. He has no belly pain, vomiting, or fevers. He assures you that this is his “hemorrhoid pain,” and it is not unusual; he just ran out of cream. He does have nonthrombosed external hemorrhoid. Give him the cream and send him home, right?



The cream helped, but now his right buttock is hurting a lot. No belly pain, vomiting, or rectal bleeding. No pain with bowel movements. A genitourinary exam reveals that his right buttock has an area of induration, warmth, and erythema. Labs show an elevated white count. The CT scan shows a gas-containing mass and marked soft tissue swelling.

Bottom Line: Soft tissue infection + POOP = ?

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Patient 3

A 25-year-old intoxicated man says his leg hurts, and he is unable to bear weight. He was inner tubing with some buddies earlier in the day, and he fell. He denies numbness or tingling. The x-ray shows a tibia fracture. Orthopedics says not to worry about it. You splint it, and tell him to keep it elevated. He goes to the waiting room to wait for his ride home.

Waiting for his ride, he begins to sober up, and he suddenly realizes how much pain he is really in. He re-registers, and tells you it is starting to feel numb. Compartments are soft.

Bottom Line: Extremity injury + POOP = ?

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Patient 1 had mesenteric ischemia; Patient 2 had necrotizing fasciitis, and Patient 3 had compartment syndrome. How did you do? Tell us at

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