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Abdominal Mass

10/29/2012

A four-year-old boy is brought in by his mother for 3 weeks of abdominal pain, having been to two other EDs this week, diagnosed with constipation. She brings him in today because now he has two days of “red urine”. No fever, nausea, vomiting, or diarrhea. He is eating well. T 37.9 HR 100 100/60 RR 22 100% RA. He has no tenderness to palpation on abdominal exam, but has what appears to be a left flank-abdominal mass. While he is waiting to be registered, his mother notes that he is “acting funny – why is he so tired?”. You re-examine him to find an altered young boy, diaphoretic, HR 120. Which of the following is the best choice for immediate intervention?

    A.   Initiate fluid resuscitation with 20 mL/kg IV bolus over five minutes
    B.   Give 3 mL/kg of 10% dextrose and monitor
    C.   Give Tylenol 15 mg/kg PR and re-assess
    D.   Give 2 mL/kg 25% dextrose and monitor

In the meantime, a quote -- "Medicine is not a field in which sheep may safely graze."

Answer

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My Heart is Pounding!

10/22/2012

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A 55-year-old woman with a history of anxiety and hypertension complains of palpitations increasing in frequency over the past week. She is under considerably more stress at work, with job cuts looming for several employees. Her last episode was typical of her previous – it lasted two to three minutes while she was at her desk: “my heart was pounding so badly it went up my neck and into my head!” She has no complaints of chest pain, shortness of breath, nausea, or diaphoresis with these episodes. The remainder of her history is unrevealing and her vital signs and physical examination are normal. Her electrocardiogram (ECG) in the ED is normal.

Regarding this patient’s risk for an arrhythmia, which of the following is the BEST answer:

    A.     Her history puts her at high risk for a significant arrhythmia
    B.     A normal examination and a normal ECG in this patient make a clinically  significant arrhythmia much less likely
    C.    Her lack of high risk symptoms places her at low to moderate risk for an arrhythmia
    D.    Her history of anxiety should be pursued further .

In the meantime, a quote -- "Your prayer must be for a sound mind in a sound body (mens sana in corpore sano)." -- Juvenal, Roman satirist, c. AD 60-130

Answer

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Agitation

10/15/2012

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A 13-year-old girl is brought in by ambulance after her friends called because she was “acting stupid”. The paramedics report that the other girls mentioned her snorting some “Vanilla Sky”.

On arrival, you see an agitated, hallucinating young girl without evidence of trauma; her glucose in the field is 122. T 37.9 HR 118 BP 142/68 RR 22 98% RA. Her general exam is significant for diaphoresis, slight tremulousness, reactive 5 mm pupils bilaterally, and a tachycardic exam.   Her friends arrive soon after frantically roaming the department, offering no useful information, and quickly leaving after seeing her lying in the gurney.

Regarding her presentation, which of the following is the BEST answer:

    A.    Her large pupils are pathognomonic for anticholinergic toxicity
    B.    Her elevated heart rate indicates that she must have taken a hallucinogenic agent
    C.    Her diaphoresis helps to distinguish the toxidrome
    D.    This particular drug causes mydriasis, profound obtundation or coma, and rapid resolution

In the meantime, a quote -- "When meditating over a disease, I never think of finding a remedy for it, but, instead, a means of preventing it." --Louis Pasteur (1822-1885) Address to École Centrale des Arts et Manufactures, Paris, 1884

Answer

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Wheezing after IV Contrast

10/9/2012

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A 66-year-old man with a history of hypertension and smoking complains of acute-on-chronic dull, unrelenting abdominal and back pain over the past several hours. He has been “under a lot of stress lately” and occasionally suffers from anxiety. He has no fever, nausea, vomiting, or diarrhea. His vital signs show T 37.8 HR 92 BP 166/80 RR 12 98% RA. His exam shows diffuse mild abdominal tenderness to deep palpation; he has normal pulses. A bedside ultrasound of his abdomen is very limited by habitus and bowel gas.

A CT abdomen/pelvis is ordered with IV contrast. During the scan, your patient has difficulty breathing and becomes diaphoretic. You respond to the radiology suite to find a flushed man in moderate distress with wheezing. Regarding his management, which of the following is the single BEST answer:

    A)     He should never be given IV contrast again
    B)     Give steroids and diphenhydramine and watch for improvement; hold the epinephrine for now due to his age     and risk factor.
    C)     Give 0.5 mg of 1:1,000 epinephrine IM now.
    D)     Give 0.3 mg of 1:10,000 epinephrine IM now

In the meantime, a quote -- "For want of timely care, Millions have died of medicable wounds." - John Armstrong, physician and poet (1710-79) Act of Preserving Health

Answer

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Knee Pain

10/1/2012

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An 11-year-old boy presents with acute onset left knee pain. The boy states that he was running the bases during a baseball game, when he felt a “pop”, and fell on his left knee. He has no past medical history. On exam, he has normal vital signs. His head-to-toe exam is normal, except for a swollen and painful left knee; he is neurovascularly intact distally.

His left knee plain radiographs are below:

Regarding his presentation and management, which of the following is the BEST answer:

    A.    This is a common presentation in his age range; once reduced, his fracture will heal readily
    B.    This is a significant comminuted fracture as demonstrated by the lateral film; he will require an intramedullary rod
    C.    He will require both medical and surgical intensive treatment
    D.    He should be evaluated for a deep bone infection

Answer

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Abdominal Mass

My Heart is Pounding!

Agitation

Wheezing after IV Contrast

Knee Pain

Timothy Horeczko, MD, MSCR, FACEP, FAAP

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