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Tubo-ovarian Abscess

32F no PMH, p/w fever and abdominal pain x 5 days. Seen 5 days ago at OSH and treated for UTI w bactrim. Seen 2 days later, switched to doxycycline for presumed PID. GC/chlamydia negative.  Returns today w persistent pain and fever. Pain is lower, bilateral, R>L with mild distention. No urinary or vaginal symptoms. Passing gas. LMP 1 week ago, Urine preg neg 2 days ago. No prior surgeries. Unable to tolerate PO x 2 days, feels too sick to eat, has some vomiting as well.


Today is febrile to 100.6, hemodynamically stable, HR 80, BP 121/86, sat 99% RA, 18 RR. Abd soft, mild distented,, +BS, +bilat lower ttp, R>L with rebound and guarding, pelvic with yellow watery discharge, no CMT, +adnexal fullness. Labs notable for leukocytosis 17, lactate 1. CT abd/pelvis to r/o appendicitis, shows normal appendix but also bilateral pyosalpinx with mass effect on bladder/uterus, causing bilat hydronephrosis.  Treated w zosyn, doxycycline, 2L IVF. Pt goes to IR for drainage of bilateral TOA and does well. Cultures all negative.



“Transvaginal ultrasound image of the left adnexa showing a tuboovarian abscess. A complex solid and cystic mass is identified in the left adnexa. The tuboovarian abscess is seen as a complex cyst (large arrow) and fluid filled tube (short arrow).” Source- uptodate


Tubo-ovarian Abscess

—-  Usually a complication of PID

—-  Approx 66,000 cases annually

— – Ages 15- 40

— – Microbiology: polymocrobial

— – Send testing for GC/chlam and treat PID

— – Presentation: lower abdominal pain, fever, and vaginal discharge; ruptured à acute abdomen, septic

— – Imaging: US, CT

— – Treatment: Broad spectrum IV abx, surgical drainage

— – Complication: Risk of rupture à sepsis, mortality 1.7-3.7%




Reference: Uptodate


Kanavel’s Sign

Kanavel’s sign: clinical sign found in patients with flexor tenosynovitis (infection of flexor tendon sheath of hand)

-       involved digit kept in flexed position

-       tenderness to palpation over tendor sheath

-       pain with passive extension of digit

-       fusiform swelling of digit





Ultrasound Guided Lp

Ultrasound guided LP


Equipment needed:

-       high-frequency (small parts linear probe) for patients with normal weight

-       low-frequency 2-4 MHZ probe (abdominal curvilinear probe) for obese patients

-       transducer gel

-       skin marking pen

-       LP tray


Positioning: left lateral decubitus or seated position



1-   Identify spinous process which signifies the midline of the spine. Probe must be in transverse position, probe marker to clinician’s left side, at level of iliac crest. Spinous process looks like cresent shape hyperechoic structure with posterior acoustic shadowing.





2-   Mark the midline with a skin marking pen at the center of the probe. Drag the probe superiorly (head) and inferiorly (feet) and again mark the midline of the spine.

3-   Rotate the transducer to the sagittal (longitudinal) plane, with probe marker pointed at patient’s head. The probe should be parallel with patients spine and in between spinous processes previously marked.  The spinous processes again appear as hyperechoic cresent shapes.






4. Mark the space between the two spinous processes which is the interspinous space, on left and right side of probe.

5. The point of intersection represent the middle of the interspace and most ideal place for LP needle insertion.



6. Proceed with LP as you usually would. Instruct patient not to move as this may obscure landmarks and skin markings.


Reference: http://emedicine.medscape.com/article/1458641-overview#showall   Written by our very own Sinai EM attending’s Suzie Bentley and Danny Duque!



Chlamydia Conjunctivitis in Newborn

10d male p/w R eye tearing and discharge x1 day. Today purulent. Born FT via NSVD, uncomplicated pregnancy and delivery. No fever. No vomiting, diarrhea. No URI. Taking good PO.  On exam, AFVSS, R eye diffuse soft tissue swelling, crusting to lashes, conjunctiva injected with purulent discharge:



Chlamydia Conjunctivitis in Newborn

Transmission – from mothers genital flora during vaginal delivery

Incubation period- 5 to 14 days after delivery

Presentation – mild watery discharge that progresses to mucopurulent discharge, swelling of eyelid, thickened conjunctiva (chemosis), pseudomembrane may form on conjunctiva, conjunctiva may become friable and bleed.

Complications- Granulation tissue, corneal and conjunctival scarring may occur if left untreated

Diagnosis – culture is gold standard. Consider testing all newborns less than 1 month age with conjunctivitis.

Treatment- AAP and CDC recommend oral erythromyicin 50 mg/kg/day PO in 4 divided doses for 14 days

Prevention- prenatal maternal screening


Our case, underwent full sepsis work up, WBC 20.7, normal diff,  normal CXR, LP, urine, blood cultures. Did well after antibiotic treatment.



Kimberly Kahne, MD- Thank you to our PEM fellow for the case!

Uptodate- Chlamydia trachomatis infections in the newborn


Inferior Shoulder Dislocations

55 yo F presents with shoulder pain after fall from bicycle:


Also known as “luxatio erecta”  - to place upward


Inferior shoulder Dislocation




Mechanism of injury: fall and sudden grasp of object above head resulting in hyperabduction

Presentation: Patients hold arm above head and is unable to adduct, looks like a person raising their hand to ask a question

Exam: Can palpate humeral head along lateral chest wall, forearm is pronated, unable to adduct, elbow usually flexed above head. Check distal radial pulse and axillary nerve  pin prick sensation at shoulder.

Assoc injuries: Axillary artery, brachial plexus – most often axially nerve. Neurovascular deficits usually resolve with prompt reduction. Also associated with rotator cuff tears and greater tuberosity fractures.

Imaging: Reveals humeral head beneath glenoid

Reduction: Closed reduction often successful with traction-countertraction and slow gentle adduction of affected arm. Open surgical reduction is required when humeral head in a tear of the inferior capsule, also known as “buttonhole deformity”






Simon and Sherman, Emergency Orthopedics 6th Ed, pgs 353-54


Rosh Review