Category: Genitourinary Emergencies
Stabbing LLQ Pain
A 19-year-old female presents to the emergency department (ED) complaining of 48 hours of worsening, stabbing left lower quadrant abdominal pain. The patient notes an intermittent, foul-smelling vaginal discharge for the past week. She also endorses fever, nausea, vomiting, dyspareunia, dysuria, and generalized fatigue. The patient is sexually active with one male partner and uses combination OCPs in conjunction with inconsistent utilization of condoms. She denies vaginal bleeding, fevers, jaundice, vomiting, constipation, or diarrhea. Her last menstrual period (LMP) ended 16 days ago and was typical of her usual menses. The patient has a history of menarche at 14 and coitarche at 17. She denies any use of tobacco but admits intermittent alcohol and marijuana use. She has no past medical or relevant family history. There are no known drug allergies.
Physical exam reveals a well-developed female in mild discomfort but no acute distress. Her vitals are unremarkable except for a temperature of 38.5 and a heart rate of 102. Her abdominal exam reveals moderate tenderness to palpation, worse in the left lower quadrant, with no rebound tenderness. There is no costovertebral angle tenderness, Rovsing sign or McBurney point tenderness. External genitalia is unremarkable. A pelvic exam demonstrates foul purulent discharge in the vaginal vault emanating from the cervical os with no visible blood products. Cervical motion tenderness and pain on palpation of bilateral adnexa are present. Left adnexa is more tender and has a palpable mass on it.
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A 75-year-old male with voiding difficulty
Urinary Catheter Placement chapter written by Gul Pamukcu Gunaydin from Turkey is just uploaded to the Website!
A 75-year-old male patient was admitted to the emergency department with difficulty voiding. He had this complaint for over a year, and tonight, although he felt pain and distention in his lower abdomen, he could not urinate at all. On his physical exam, the patient had a palpable mass that was thought to be the distended bladder. He was agitated and tachycardic. He was diagnosed with acute urinary retention, and initial attempt to insert urinary indwelling catheter was failed. The second attempt with a Coude catheter was successful and 2 liters of urine was drained gradually. His rectal exam revealed prostate enlargement. He was discharged with instructions, uneventfully.
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A 19-year-old female
Tubo-Ovarian Abscess chapter written by Matthew Lisankie, Charlotte Derr, Tomislav Jelic from Canada is just uploaded to the Website!
A 19-year-old female presents to the emergency department complaining of 48 hours of worsening, stabbing left lower quadrant abdominal pain. The patient notes an intermittent, foul-smelling vaginal discharge for the past week. She also endorses fever, nausea, vomiting, dyspareunia, dysuria, and generalized fatigue. The patient is sexually active with one male partner and uses combination OCPs in conjunction with inconsistent utilization of condoms. She denies vaginal bleeding, fevers, jaundice, vomiting, constipation, or diarrhea. Her last menstrual period (LMP) ended 16 days ago and was typical of her usual menses. The patient has a history of menarche at 14 and coitarche at 17. She denies any use of tobacco but admits intermittent alcohol and marijuana use. She has no past medical or relevant family history. There are no known drug allergies.
Physical exam reveals a well-developed female in mild discomfort but no acute distress. Her vitals are unremarkable except for a temperature of 38.5 and a heart rate of 102. Her abdominal exam reveals moderate tenderness to palpation, worse in the left lower quadrant, with no rebound tenderness. There is no costovertebral angle tenderness, Rovsing sign or McBurney point tenderness. External genitalia is unremarkable. A pelvic exam demonstrates foul purulent discharge in the vaginal vault emanating from the cervical os with no visible blood products. Cervical motion tenderness and pain on palpation of bilateral adnexa are present. Left adnexa is more tender and has a palpable mass on it.
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A boy with scrotal pain
Testicular Torsion chapter written by Sujata Sheth Kirtikant from Singapore is just uploaded to the Website!
A 16-year-old male was sleeping when he suddenly started to feel left sided lower abdominal pain. He continued to bear through the pain for another 30 minutes until he started to vomit. At this time he decided to go to the nearest hospital, which is about 15 minutes away. When he reached the hospital his vital signs were as follows: blood pressure: 120 over 60 mmHg, heart rate: 120 bpm, respiratory rate: 20 bpm, Temperature 36.5, Pain score is 10 out of 10 and SP O2 was 100% on room air. Physical shows a swollen right scrotum with significant tenderness. What is the next step?
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A 13-year-old with testicular pain
In case you didn’t encounter a patient with testicular pain today!
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A 24-year-old female with pelvic pain
How ectopic pregnancy should be delivered to the students/interns.
Clear, to the point!
Ectopic Pregnancy
by Dan O’Brien, USA
A 24-year-old woman presents to the emergency department with the complaint of lower abdominal pain and vaginal spotting. She has never been pregnant. Her last normal menstrual period was two months ago. She had light spotting last month and states that her period this month is late. Her history is notable for one episode of lower abdominal pain two years ago thought to be the pelvic inflammatory disease that responded to a two-week course of oral antibiotics. She has no medical allergies and is not on any medications.
Review of systems and family history are unremarkable. Her social history is significant in that she is in a monogamous relationship and is not using birth control. Her general appearance is that of a well-developed female with a temperature of 37ºC, a blood pressure of 110/70 mm Hg and a pulse of 90 bpm. An examination of her abdomen reveals normal bowel sounds, no masses, distension, organomegaly or rebound tenderness. She is mildly tender to palpation in the left lower quadrant. Pelvic exam reveals left adnexal tenderness without palpable masses. The rectal exam is normal with hemoccult negative stool. Pertinent lab values: urine dip pregnancy testing is positive, quantitative serum B-hCG is 2000 mIU/mL, hemoglobin 13 gr/dL, hematocrit 40%. She is Rh-positive. A transvaginal ultrasound performed by the emergency physician during the pelvic exam fails to demonstrate an intrauterine pregnancy. There is a small amount of fluid in the rectouterine cul-de-sac. 2 cm ectopic pregnancy was identified. Two large-bore IV’s were started, the patient was crossmatched for blood and OB-GYN was consulted. Treatment options were discussed.
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