Imperforate Hymen and Hematometrocolpos in a Female With Back Pain and Urinary Retention.

A 12-year-old female with primary amenorrhea presented to the emergency department with episodic low back pain, suprapubic discomfort, and acute urinary retention. A protruding purple mass was noted at the vaginal introitus consistent with an imperforate hymen. Point-of-care bedside transabdominal ultrasonography revealed a distended uterus containing hypoechoic material. The patient underwent formal pelvic ultrasonography, which revealed a markedly enlarged uterus containing a large number of blood products, thinned myometrium, and a distended vaginal canal consistent with hematometrocolpos secondary to imperforate hymen. Imperforate hymen is a rare congenital anomaly of the female urogenital tract, in which the hymen obstructs the vaginal opening causing a vaginal outlet obstruction. Vaginal outlet obstruction secondary to imperforate hymen may lead to retrograde menstruation with a collection of blood within the uterus and vagina, which is termed hematometrocolpos. Treatment is based on identifying and treating the underlying imperforate hymen with surgical approaches. The growing use of bedside ultrasonography allows the clinician to rapidly and accurately diagnose hematometrocolpos. The use of point-of-care bedside ultrasonography can serve as an essential tool as delayed diagnosis and treatment of this rare condition are associated with significant morbidity and lifelong infertility.

Charles Bonnet Syndrome as Another Cause of Visual Hallucinations.

Charles Bonnet syndrome (CBS) presents as gradual vision loss and associated visual hallucinations in a patient who is otherwise neurologically and psychiatrically intact. This syndrome presents primarily as ophthalmologic disease, however, may be secondary to an ischemic stroke or tumor in the occipital lobe. Patients present with a complaint of vivid visual hallucinations ranging from spots and geometric shapes to seeing people, distorted figures and landscapes.First noted in the 1760s, CBS did not reach the western scientific community until the early 1980s. Our patient reported seeing her dog and deceased mother only when looking left. She was having an experience of phantom images in addition to a visual field impairment but was otherwise of sound mind with no gross neurological deficits. Computer topography of the brain revealed a subacute infarct in the right posterior occipital lobe. The patient was ultimately diagnosed with CBS following magnetic resonance imaging and ophthalmology consultation at tertiary center. Diagnosis may be delayed by lack of symptom reporting as patients do not want to carry a stigma as 'crazy.' Further, physician awareness of this etiology is low and a better understanding of the disease will prevent missed diagnosis as well as lack of appropriate consultation and follow-up. Treatment includes close outpatient ophthalmology care, maximizing existing vision and lifestyle changes including adjustments in lighting, decreasing stress and increasing socialization. Trials of prescription treatment (i.e., antipsychotics, serotonin reuptake inhibitors, antiepileptics) have shown only anecdotal evidence at efficacy. CBS is an uncommon presentation of cerebral vascular disease that warrants the attention of emergency department physicians.

Pain scores show no monotonic upward or downward trend over time.

BACKGROUND: Self-reported pain scales are commonly used in emergency departments (EDs). The 11-point (0-10) numerical rating scale is a commonly used scale for adults visiting EDs in the United States. Despite their widespread use, little is known about whether distribution of pain scores has remained consistent over time. OBJECTIVES: The objective of this study is to determine if there were upwards or downwards (monotonic) trends in pain scores over time at a single hospital. METHODS: Retrospective chart review for the years 2003-2011. All pain scores for May 1(st) and 2(nd) of those years were collected. Multinomial logistic regression was used to model the probability of a patient rating their pain in each of 11 categories (scores 0 to 10) as a function of the calendar year. Additional analysis was carried out with pain scores grouped into four categories. RESULTS: Data were collected from 2934 patient charts. Pain scores were recorded in 2136 charts, and 1637 of these pain scores were above zero (i.e., 1-10). The pain score distribution differed significantly over time (p = 0.001); however, there was no monotonic (single-direction) trend. CONCLUSION: Although there were significant shifts in pain scores over time, there is not a significant monotonic trend. At this hospital, there was no "inflation" or "deflation" in pain scores over time. Shifts in distribution, even when not in a single direction, may be important for researchers examining pain scores in the ED.