Chief Complaint: Patient presents with LLQ Abdominal Pain & Emesis X 1 day
History of Present Illness (HPI)
15 yo M with PMx of ADHD presents with his mother to the ER c/o LLQ abdominal pain. Pt states that he was trying to defecate last night but failed and then the pain started. Pt had normal bowel movement the day before. Pt reports that he has a pulsating sharp pain at LLQ that does not radiate anywhere. Pt vomited once in the ER without any blood in the vomitus. Pt denies trauma, fever, chest pain, shortness of breath, sick contacts, or any recent travel. Patient also denies any chills, diarrhea, cough, headaches and any myalgias.
Past Medical History:
ADHD (attention deficit hyperactivity disorder) – Pt does not take anything for it
No past surgical history
Review of Systems
General: Negative for appetite change, fever, chills, weakness, diaphoresis, fatigue, or weight loss.
Eyes: Negative for visual disturbances, blurry vision, fatigue, lacrimation, photophobia, or pruritus.
Respiratory: Negative for orthopnea, dyspnea, wheezing, hemoptysis, cyanosis, cough, paroxysmal nocturnal dyspnea
Cardiovascular: Negative for chest pain, hypertension, palpitations and leg swelling
Gastrointestinal: Positive for abdominal pain, constipation, vomiting and sharp pain in the LLQ with no radiation. Negative for anal bleeding, blood in stool, diarrhea and nausea.
Genitourinary: Negative for dysuria, incontinence, hematuria, penile pain, scrotal swelling and testicular pain
Musculoskeletal: Negative for back pain and myalgias.
Neurological: Negative for dizziness and headaches.
Physical Exam
General: Patient is awake, alert, and oriented X 3. Pt is writhing in his hospital bed leaning towards his left side. He has a normal looking appearance and looks his stated age. Patient is obese.
Head: Normocephalic and atraumatic
Eyes: Pupils are equal, round, and reactive to light.
Skin: Skin is warm and dry. Capillary refill takes less than 2 seconds
Cardiovascular: Normal rate and regular rhythm. Normal pulses. S1 and S2 heart sounds with no murmur heard. No splitting of S2 or friction rubs appreciated.
Pulmonary: Clear to auscultation bilaterally. No respiratory distress. Normal breath sounds throughout. No stridor, wheezing, rhonchi, or rales heard.
Abdominal: Abdomen is flat. Bowel sounds are normoactive in all four quadrants. There is no distension and no mass that is seen or felt. There is no abdominal tenderness, rebound tenderness or guarding. No hernias are present.
Genitourinary: Penis is normal appearing and uncircumcised. Right testis does not have a mass present nor have any tenderness, swelling, hydrocele or varicocele. Right testis is descended. Left testis does have swelling. No tenderness is present. Left testis is descended. Cremasteric reflex is present for both testicles. Positive Prehn sign on the left testicle.
Musculoskeletal: No swelling, tenderness, deformities, or signs of injury. No edema seen on the right or left lower legs.
Vital Signs
BP: 130/70 (right arm)
Pulse: 92
Temp: 98.4 F
Resp: 20 breaths/min
Weight: 215lbs
Height: 68 inches
BMI: 32.7
Oxygen Saturation: 99% on room air
DDx
Varicocele
Testicular Torsion
Epididymitis
Hydrocele
Nephrolithiasis
Inguinal Hernia
ASSESSMENT + PLAN
15 y/o M with PHx of ADHD presents with his mother to the ER c/o LLQ abdominal pain that started last night. No tenderness to palpation on all four quadrants of the abdomen. Swollen left testicle was noted with no erythema, rashes, or lesions. Left testicle has no tenderness to palpation, and cremasteric reflex is present with positive Prehn sign.
Set up an IV line. Give 8mg Zofran IV to alleviate the vomiting and Ibuprofen (Motrin) for the pain and give intravenous fluids – LR 500 ml bolus with 125 ml for maintenance. For labs we will need abdominal X-ray, US Doppler for testes, CBC, CMP, and UA. Also, a urology consult, if needed after the US results
LAB and IMAGING RESULTS
Labs: lipase 10, WBC 10.69, CRP 6.50, and Glucose is 167, but otherwise within normal limits.
Abdomen X-ray: Air is seen within a nondistended stomach. There is a paucity of small bowel gas. Mild multifocal colonic stool. There is no evidence of free air. The visualized osseous structures demonstrate no acute abnormalities.
Doppler US:
- MILD ASYMMETRICALLY PROMINENT LEFT EPIDIDYMAL HEAD WITH INCREASED COLOR DOPPLER PLEASE CORRELATE CLINICALLY FOR LEFT-SIDED EPIDIDYMITIS
- MINIMALLY MORE PROMINENT LEFT TESTICLE COMPARED WITH THE RIGHT HOWEVER THE RIGHT TESTICULAR PARENCHYMA APPEARS HETEROGENEOUS AND POSSIBLY EDEMATOUS. COLOR DOPPLER IS SEEN WITHIN BOTH TESTICLES BUT APPEARS EITHER INCREASED ON THE RIGHT OR REDUCED ON THE LEFT PLEASE CORRELATE CLINICALLY FOR RIGHT SIDED ORCHITIS.
- LEFT TESTICULAR MICROLITHIASIS
- LEFT-SIDED VARICOCELE.
As per the Urology consult, they recommended Bactrim DS for 2 weeks and NSAID’s PRN
