On a Wednesday afternoon, I see a 10 yo obese male who falls awkwardly
in gym class and suffers a markedly angulated radius-ulna fracture with
a 'microscopic' opening in the skin. Under ketamine sedation in the ED
the orthopedist irrigates him, reduces him and gives him IV antibiotic.
He's in my ED most of the day and goes home on T3's (codeine) and keflex
per the ortho. On Friday morning he complains of arm pain for the first
time and the mother gives him a T3. Forty-five minutes later he vomits.
He has progressive arm pain that night, and won't take anymore T3s. He
comes to my ED on Friday night with arm pain and a temp of 100.5. I call
the ortho, take the cast down, and everything looks fine- he's recasted.
I give him some IV fluids and he drinks OK. I do a WBC (don't ask me
why) and it's 20K. He's been in my ED for four hours and now he
complains of a feeling that he needs to urinate but can't. Two hours
later he urinates and feels better. His belly is obese, but soft. His
U/A is negative. I send him home with oxycodone. Can you guess the rest
of this story?
My first patient on my Sunday night shift is this same kid with a 102
temp, peritoneal signs, and a ruptured appendicitis. I seriously
considered opening a bookstore the next day.
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