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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Pain Relief

Healthcare providers should have a sound understanding of the anatomy, physiology, and psychology of addictive behaviors. A focused history and examination should concentrate on items that can indicate inconsistencies or falsifications associated with inappropriate drug-seeking behavior. It was always difficult as a decision has to be made between “losing” to drug seekers and denying analgesia to patients who are genuinely in need. It is best to give patients the benefit of the doubt with due diligence.

from iEM's Drugs for Pain Relief chapter Tweet

"Drugs for pain relief' chapter written by Nik Ahmad Shaiffudin Nik Him and Azizul Fadzi was added into the content list.

Neck pain after a bar fight

674.1 - C1 fx - 6-7 sublux

In case you didn’t encounter a young trauma patient today!

You are working in a rural hospital. A 34-year-old male trauma patient was brought to the ED by his friends! You applied primary and secondary survey. The patient describes only neck pain. He has a central tenderness at the c-spine area. The facility does not have a CT scan, and you order c-spine X-ray. 

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!