20 year old male presents with a one hour history of left testicular pain and swelling which began acutely after he got out of the shower. He denies dysuria, urethral discharge or trauma. He states that this has never happened before and says this is the worst pain he has ever had in his entire life. Since arriving to the ED he has become nauseous and has vomited several times.
Afebrile, vitals signs stable.
GU exam reveals a horizontal lie to his left testicle with significant tenderness. Absent cremasteric reflex. Remainder of the GU exam is normal. No inguinal lymphadenopathy and the abdominal exam is unremarkable.
Evaluation and Management:
The patient was seen nearly immediately after arrival via EMS and we were concerned for a possible testicular torsion and therefore elected to perform a manual detorsion procedure. While preparing for this we grabbed the ultrasound machine, paged urology and had the nurse place a peripheral IV to administer 1mg of Dilaudid. Although emergency point of care (POC) scrotal ultrasound (US) is not a standard US exam done in the Emergency Department (ED), we decided to attempt the exam to see if there was blood flow to the affected testicle prior to attempted detorsion and then to repeat the exam after the procedure.
US image Review:
POC Scrotal US was performed using the high frequency linear probe. The bilateral testes were scanned in transverse and sagittal planes:
55yo female presents to your ED with a 1 month history of progressive dyspnea. She has a history of HTN and schizophenia, is on multiple antihypertensive medications (admits to “occasional” non-compliance) as well as Geodon (claims to be much better about taking this med than the others). Denies illicit drugs. Other than fatigue she really has no other symptoms including chest pain or fever and has an unremarkable exhaustive review of systems.
Afebrile, BP is 185/90, HR 72, RR 16, SpO2 97% RA. Other than 1+ edema in the LE’s her exam was unremarkable; of note, neck veins were difficult to assess because of her body habitus (obese), her lungs were clear and no murmurs were appreciated. Distal pulses were full and equal bilaterally.
35yo female presents to your ED with acute right flank pain. The pain is severe and intermittent, x approx 24h, associated with intermittent nausea and 2 episodes of non-bloody, non-bilious emesis. No diarrhea, constipation, anorexia. No fever. Urine reported to be dark, denies hematuria, no vaginal discharge or bleeding. LMP 1 wk ago. PMH notable for nephrolithiasis with 1 previous episode of ureteral colic that was managed conservatively 2 yrs ago.
Afebrile, BP 160/85, HR 105, RR 22, SpO2 98% RA. Her exam reveals right mid-abdomen mild tenderness, neg Murphy’s/McBurney’s point tenderness. Mild right flank tenderness and a normal pelvic examination.