1/48. Acute flank pain: an unusual presentation of a spinal AVM.The authors report the case of a 6-year-old boy with a spinal cord arteriovenous malformation (AVM) who presented with acute flank pain and a delayed onset of paraplegia. An early diagnosis of a spinal cord AVM was made difficult by the absence of neurological findings on initial evaluation. Included is a description of his clinical course, and the presentation of spinal AVMs to the emergency physician is discussed.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/48. Sigmoid colon carcinoma metastatic to the myometrium.Metastases to the uterus from extragenital cancers are significantly rarer than metastases to the ovaries. Of the approximately 200 cases of metastases to the uterus from extragenital cancers that have been reported in the literature, more than half are cases of metastases from breast carcinoma and only 16 are cases of metastases from colorectal carcinoma. A case of isolated metastases restricted to the myometrium of the right uterine comu from sigmoid colon carcinoma, without involvement of the ovaries, is described. The patient who six months previously had surgery for sigmoid colon carcinoma presented with right lower abdominal pain and a palpable mass in the region of the right uterine cornu. The diagnosis of isolated metastases restricted to the myometrium of the right uterine cornu was confirmed by total abdominal hysterectomy and bilateral salpingo-oophorectomy. This case illustrates that a growing uterine mass in a patient with a history of primary extragenital cancer, regardless of whether abnormal uterine bleeding is present or absent, should alert the physician to consider the possibility of uterine metastases.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/48. Perforation of jejunal diverticulum: case report and review of literature.We report the case of a 90-year-old woman, previously diagnosed with jejunal and colonic diverticula, who presented with left lower quadrant abdominal pain suggesting either colonic diverticulitis or ischemic colitis. A computed tomography scan revealed a perforated jejunal diverticulum with abscess formation. The patient promptly was treated surgically without complications. A review of the literature indicates the rarity of perforation of jejunal diverticula and the difficulty of early diagnosis. We discuss the etiology, pathogenesis, diagnosis, and management of this rare entity. It is important for primary care physicians to be familiar with this disease. Delay in work-up often results in catastrophic consequences.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/48. nephrolithiasis with unusual initial symptoms.OBJECTIVE: To describe a less common initial symptom of nephrolithiasis, its diagnostic pitfalls, risk factors, and mimicry of other conditions. Intervention and long-term management of nephrolithiasis is also discussed. CLINICAL FEATURES: A Caucasian man aged 25 years had sudden bilateral inguinal and occasional periumbilical pain. The initial symptom suggested an abdominal pathologic condition; however, costovertebral angle pain followed 1 hour later with no radiation between the 2 anatomic sites. The initial urine dipstick result was negative for hematuria, but a kidney, ureter, and bladder radiograph revealed a smooth 2-mm x 3-mm stone lodged at the left: vesico-ureteral junction. INTERVENTION AND OUTCOME: The patient was referred to a regional university medical center to receive extracorporeal shockwave lithotripsy several days after his initial visit. He was given pain medicine for the waiting period and received daily lumbar spine adjustments with a mild reduction in pain. He eventually received ureteroscopic laser lithotripsy because the shock-wave unit had malfunctioned before his appointment. The fragment analysis showed a calcium oxalate composition, and the patient was advised to lower his intake of oxalates. The patient had become a vegetarian approximately 3 months before this first stone episode. CONCLUSION: nephrolithiasis is a condition commonly seen in chiropractic practice. Although it is usually easy to recognize, the diagnosis can be elusive if the typical historic factors and diagnostic results are absent or altered. The short-term management of nephrolithiasis is pain management, stone elimination, and the collection of a specimen to identify the composition and underlying metabolic abnormality. Long-term management is to prevent the recurrence of stones. Conservative comanagement by the chiropractic physician can be implemented through nutritional means.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/48. Abdominal compartment syndrome in a patient with congenital megacolon.A 13-year-old male with a history of chronic congenital megacolon presented to the emergency department with a 1-day history of increasing abdominal pain, distension, and emesis. The patient was admitted for bowel disimpaction and irrigation. The patient rapidly developed an acute abdominal compartment syndrome because of his massive colonic dilation. Surgical decompression resulted in a reperfusion phenomenon and ultimately resulted in coagulopathy and patient demise. This case presents a unique cause of the abdominal compartment syndrome and discusses the implications to the emergency physician.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/48. enoxaparin associated with hugh abdominal wall hematomas: a report of two cases.enoxaparin is a low-molecular-weight heparin used for prophylaxis against deep venous thrombosis. Indications include hip and knee replacement surgery, risk of deep venous thrombosis during abdominal surgery, and prevention of ischemic complications of unstable angina and non-Q-wave myocardial infarction. Its efficacy in the prevention of the above complications has been previously studied; however, the liberal use of enoxaparin is not without incident. Complications of enoxaparin include hemorrhage, thrombocytopenia, and local reactions. Since 1993 there have been more than 40 reports of epidural or spinal hematoma formation with the concurrent use of enoxaparin and spinal/epidural anesthesia or spinal puncture. Herein reported are two cases of abdominal wall hematomas in patients receiving prophylaxis with enoxaparin. Both patients sustained an unexplained fall in the hematocrit and abdominal pain. A CT scan confirmed the diagnosis. One patient recovered uneventfully; however, the other patient, on chronic hemodialysis, became hemodynamically unstable and hyperkalemic and sustained a fatal cardiac arrhythmia. An extensive review of the literature revealed no similar cases of abdominal wall hematomas associated with enoxaparin although other complications, including spinal and epidural hematomas, psoas hematomas, and skin necrosis have been reported. The extended use of enoxaparin as an anticoagulant requires the physician to be vigilant of these rare complications. Bleeding can occur at any site during therapy with enoxaparin. An unexplained fall in the hematocrit or blood pressure should lead to a search for a bleeding site.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/48. Bilateral tubal ectopic pregnancy: a tale of caution.Diagnosis of ectopic pregnancy continues to be an important challenge facing emergency physicians. The authors present a case of bilateral tubal ectopic pregnancy and discuss its clinical features and diagnostic difficulties. A review of the English-language literature on the subject is discussed. Suggestions are made on ways to increase diagnostic accuracy, reduce complications, and preserve future fertility in this group of patients.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/48. Static magnetic field therapy for pain in the abdomen and genitals.Two adolescents with debilitating, medication-resistant, chronic pain of the low back and abdomen with intermittent pain of the genitalia were diagnosed with intervertebral disk disease at spinal cord levels that correlated with their signs. Both patients had undergone multiple evaluations by physicians of different specialties and both underwent appendectomy without relief of their pain. The history of the onset of pain was important in determining the affected levels. The pain of both individuals was mimicked and localized by percussion of the vertebral spines at the level of disk protrusion. This maneuver and careful review of the history were important in making the correct diagnosis in each case. In both patients, treatment with novel magnetic devices provided rapid relief that was sustained for more than 2 years. These cases highlight the need for careful evaluation and correct diagnosis of abdominal and genital pain in young patients to avoid costly and unnecessary medical intervention and the stigma of painful debility.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
9/48. zollinger-ellison syndrome. Clinical presentation in 261 patients.We prospectively evaluated the initial presenting symptoms in 261 patients with zollinger-ellison syndrome (ZES) over a 25-year period. Twenty-two percent of the patients had multiple endocrine neoplasia-type 1 (MEN-1) with ZES. Mean age at onset was 41.1 /- 0.7 years, with MEN-1 patients presenting at a younger age than those with sporadic ZES (p < 0.0001). Three percent of the patients had onset of the disease < age 20 years, and 7% > 60 years. A mean delay to diagnosis of 5.2 /- 0.4 years occurred in all patients. A shorter duration of symptoms was noted in female patients and in patients with liver metastases. abdominal pain and diarrhea were the most common symptoms, present in 75% and 73% of patients, respectively. heartburn and weight loss, which were uncommonly reported in early series, were present in 44% and 17% of patients, respectively. Gastrointestinal bleeding was the initial presentation in a quarter of the patients. patients rarely presented with only 1 symptom (11%); pain and diarrhea was the most frequent combination, occurring in 55% of patients. An important presenting sign that should suggest ZES is prominent gastric body folds, which were noted on endoscopy in 94% of patients; however, esophageal stricture and duodenal or pyloric scarring, reported in numerous case reports, were noted in only 4%-10%. patients with MEN-1 presented less frequently with pain and bleeding and more frequently with nephrolithiasis. Comparing the clinical presentation before the introduction of histamine H2-receptor antagonists (pre-1980, n = 36), after the introduction of histamine H2-receptor antagonists (1981-1989, n = 118), and after the introduction of proton pump inhibitors (PPIs) (> 1990, n = 106) demonstrates no change in age of onset; delay in diagnosis; frequency of pain, diarrhea, weight loss; or frequency of complications of severe peptic disease (bleeding, perforations, esophageal strictures, pyloric scarring). Since the introduction of histamine H2-receptor antagonists, fewer patients had a previous history of gastric acid-reducing surgery or total gastrectomy. Only 1 patient evaluated after 1980 had a total gastrectomy, and this was done in 1977. The location of the primary tumor in general had a minimal effect on the clinical presentation, causing no effect on the age at presentation, delay in diagnosis, frequency of nephrolithiasis, or severity of disease (strictures, perforations, peptic ulcers, pyloric scarring). Disease extent had a minimal effect on symptoms, with only bleeding being more frequent in patients with localized disease. patients with advanced disease presented at a later age and with a shorter disease history (p = 0.001), were less likely to have MEN-1 (p = 0.0087), and tended to have diarrhea more frequently (p = 0.079). A correct diagnosis of ZES was made by the referring physician initially in only 3% of the patients. The most common misdiagnosis made were idiopathic peptic ulcer disease (71%), idiopathic gastroesophageal reflux disease (GERD) (7%), and chronic idiopathic diarrhea (7%). Other less common misdiagnosis were crohn disease (2%) and various diarrhea diseases (celiac sprue [3%], irritable bowel syndrome [3%], infectious diarrhea [2%], and lactose intolerance [1%]). Other medical disorders were present in 55% of all patients; patients with sporadic disease had fewer other medical disorders than patients with MEN-1 (45% versus 90%, p < 0.00001). hyperparathyroidism and a previous history of kidney stones were significantly more frequent in patients with MEN-1 than in those with sporadic ZES. Pulmonary disorders and other malignancies were also more common in patients with MEN-1. These results demonstrate that abdominal pain, diarrhea, and heartburn are the most common presenting symptoms in ZES and that heartburn and diarrhea are more common than previously reported. The presence of weight loss especially with abdominal pain, diarrhea, or heartburn is an important clue suggesting the presence of gastrinoma. The presence of prominent gastric body folds, a clinical sign that has not been appreciated, is another important clue to the diagnosis of ZES. patients with MEN-1 presented at an earlier age; however, in general, the initial symptoms were similar to patients without MEN-1. gastrinoma extent and location have minimal effects on the clinical presentation. overall, neither the introduction of successful antisecretory therapy nor widespread publication about ZES, attempting to increase awareness, has shortened the delay in diagnosis or reduced the incidence of patients presenting with peptic complications. The introduction of successful antisecretory therapy, however, has dramatically decreased the rate of surgery in controlling the acid secretion and likely led to patients presenting with less severe symptoms and fewer complications. (ABSTRACT TRUNCATED)- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/48. Left lower quadrant pain of unusual cause.The differential diagnosis of left lower quadrant abdominal pain in an adult man includes, among others, sigmoid diverticulitis; leaking abdominal aortic aneurysm; renal colic; epididymitis; incarcerated hernia; bowel obstruction; regional enteritis; psoas abscess; and in this rare instance, situs inversus with acute appendicitis. We report a case of situs inversus totalis with left-sided appendicitis and a brief review of the literature. There were several subtle indicators of total situs inversus present that were missed by the physicians and surgeons who initially evaluated the patient prior to surgery. Computed tomography scan with contrast, however, revealed the diagnosis immediately, and treatment was successfully initiated.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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