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Archive for the ‘EM3’ Category

Pelvic Mass

In EM3 on July 19, 2011 at 2:00 pm

13yo F presenting with 3days of lower abdominal pain, nausea and vomiting. 5/10 pain at rest, worse with movement or ambulation. LMP 3days ago. Pain was initially felt to be menstral cramps by her dad, but progressively worsened over the course of 3days. Seen by pediatrician and sent to an Outside hospital (OSH) ED for eval.

Vitals: Tmax 100.2 BP109/67 RR 18 100% RA weight -63.4kg.

OSH eval: WBC 13, Hgb 13; CT showed a large 11.2×12.1×8.5cm cystic mass in the middle of the pevis. The cyst was homogenous. Unclear of its origin from the CT thus an US was done. US again re-demonstrated the mass, unclear where the mass was originating from – R ovary was normal, the Left ovary was poorly visualized. Patient was transferred.

Upon arrival to our ED – Patient was a slightly overweight female. On exam, patient was very tender in the LLQ and infra-umbilical area with pain on palpation or movement; the mass was not palpated.  Her pelvic ultrasound was repeated.

What is your differential diagnosis on this patient? – Teratoma, ovarian cyst, ovarian torsion, cancer.

The repeat ultrasound suggest that the mass was likely arising from the left ovary. There was flow seen in the periphery of the mass but no flow demonstrated in the left ovary. The Right ovary was normal size with normal flow.

Teaching Points: Diagnosis of Ovarian torsion

Ovarian torsion – twisting of the ovaries usually due to an abnormality in the adenexa (either a cyst or neoplasm). more common with females that have ovarian hyperstimulation (due to fertility treatments). In young females, can occur in the context of a normal adenexa due to long fallopian tubes.

Classically – patient presents with severe unilateral lower abdominal/pelvic pain over many hours. It IS possible for patient to present with a more prolonged course thus duration of symptoms DOESNOT automatically exclude the possibility of torsion from the differential. Nausea and vomitting is common, fever may be a present but late finding.

Diagnosis is primarily made via Pelvic ultrasound – ovarian enlargement is the most common ultrasound finding. Always ask for dopplers or presence of ‘flow’ in the ovary – the absence of arterial flow may be diagnostic but early in the disease, obstruction of venous flow may be a clue. Some studies suggest an 8hr window (between ovarian torsion and detorsion in the OR) for the ovaries to be salvageable. Thus, time is ovary and even if the patient is out of the 8hr window, this is still a time sensitive diagnosis!

Treatment is surgical detorsion – Gyn or General surgery consult ASAP!

Outcome: necrosis from L fallopian tube to the L ovary were noted on laparoscopy. These were removed. The R ovaries were within normal.

Diarrhea, Diarrhea.

In EM3 on July 5, 2011 at 8:30 am

4yo F presents with diarrhea and fever. Patient was seen at the same ED the day prior for fever/vomitting and mild abdominal pain; she was  given zofran with a po challenge which she passed and was sent home. Since home, dad states she’s developed a watery yellow diarrhea, non bloody, about 17bm’s since last night. states she feels tired and has decrease po intake with some diffuse abdominal pain. still making wet diapers. patient is in daycare. no sick contacts. no recent travel.

Vitals: initial T @ 100.8    BP 114/59        HR 165     99% RA       RR 10

GENERAL_APPEARANCE: well_nourished, alert, (+)attentive, (-)smiling, (-)playful, no_acute_distress.

ABDOMEN: normal_BS, soft, mild tenderness in the abdomen (diffuse), (-)guarding, (-)rebound, no_organomegaly, no_abd_masses.

Gastroenteritis was top on the differential. Patient was observed in the ED for about 3hours, PO hydrated and fever controlled with tylenol however there was no significant change in her presentation.She still had diffuse abdominal pain, now more appreciated the in RLQ. Temp spiked to 103.2. Labs were obtained and she was sent to obtain an abdominal ultrasound.

Labs

WBC Count                     22.5      High B/L        (5-11)
Hemoglobin                    12.4               g/dL       (12-14.5)
Hematocrit                    37.2               %          (35-45)
Platelet                      337                B/L        (140-400)
Neutrophils                   76        High %          (25-40)

C-Reactive Protein            15.10     High mg/dL      (0.0-0.8)

Electrolytes were all within normal limits.


What is your diagnosis?

Teaching Point: diagnosis and management of INTUSSUSCEPTION

Definition: invagination of a part of the intestine into itself. Most common around the illeocecal junction. This causes a bowel obstruction.
The tunneled piece of bowel becomes engorged with venous blood and could potentially become ischemic, perforate and cause peritonitis. Etiology is mostly idiopathic (in about 90% of cases). Other causes include viral/ bacterial enteritis, post-op complication or a ‘lead point’ lesion such as a polyp, tumor, meckel’s diverticulum or vascular malformation.

Age: 3 mths to 6yrs old. M>F, more common within the first year of life.

Classic presentation: colicky abdominal pain + currant jelly stool + vomiting -only in 20% of cases. Board exams typically present the case as a child with cyclic abdominal pains in 15-20mins bouts, inconsolable crying, the child drawing the legs up to the chest, or a sausage shaped mass felt in the Right abdomen.

Diagnosis: is typically made via Ultrasound (almost 100% sensitive and specific in the hands of an experienced sonographer). Classic ultrasound findings – bull’s eye” or “coiled spring” lesion. XR abdomen may be useful to look for signs of obstruction or bowel perforation.

Clinical course: most patients recover within 24hours after intervention. However, mortality is close to 100% in 3-4days if there’s no intervention.

Treatment: 3 treatment options:1. Expectant management – with short segments of intussuception. 2. Enema (pneumatic or contrast) 3. Surgical

Contrast enema is diagnostic and therapeutic in approximately 95% of intussusception cases. You’ll need both a pediatric surgeon on stand by and radiologist to perform and interpret the study. About 10% of cases recur within 24hours after successful reduction.  *multiple recurrences hint towards a pathological (rather than idiopathic) cause of the intussusception*. Surgery is indicated when reduction with an enema is incomplete and patient remains symptomatic, or if there are signs of bowel perforation, necrosis or peritonitis.

Disposition: ADMIT!

Outcome: IVF bolus (20mg/kg x2) was given, Morphine was administered for pain cntrol. The patient was transferred to a children’s hospital as the therapeutic contrast enema procedure was not available for pediatrics at this hospital. Ultrasound was repeated at the children’s hospital – showed no signs of intussusception but however diagnosed a perforated appendix. Patient got IV abx and surgery. Did well post-op and was dc’ed home 2days after admission. 

Good way for us all to learn about intussusception I guess! 🙂 

GIB

In EM3 on May 2, 2011 at 5:25 pm

72 yo F with no PMHx presenting to the ED with GI bleed (gastrointestinal bleed – GIB).  Initially had about 4 Units of bright red blood per rectum. Patient stated it filled the toilet bowl prior to arrival, she’s never had GIB before, no abd pain, no Nausea/Vomiting, no other symptoms.  Colonoscopy 5 years ago revealed diverticulosis. Afebrile. Tachycardic to 100’s. BP110/70. Otherwise, pleasant, alert, no distress.

Outcome: After some sarcastic discussions on the phone, Surgery and GI both came down to the ED and at first were unimpressed b/c she had apparently stopped bleeding and had a hgb of 11.  But then she had another emptying of about 2 Units (see attached pic), follow by two more.  She was intubated and sent to CVIR for embolization, then to SICU.  Found right colic artery bleed.  Hgb dropped to 6s, close to 10 Units were transfused (she’s still here 1 week later with a hgb 7).

Teaching Points: Massive Lower GI Bleed.

Differential diagnosis: upper GI bleed, diverticulosis, angiodysplation, aorto-enteric fistula, anal fissure, hemorroids, inflammatory bowel disease, cancer.

Key points: complete a thorough H/P. Be aggressive in your management early! Order type and screen, get surgery and GI involved early even in lower GIB.