Monday, March 12, 2012


A 20 year old patient comes in with acute abdominal pain, anorexia, nausea, and vomiting. The pain started at the bellybutton, then migrated to the right lower quadrant. Exam shows fever and tachycardia. The point of maximal tenderness is 1.5 inches from the anterior superior iliac spine on a straight line from the ASIS to the umbilicus.

Challenge 1: What's this point called?

Palpation of the left lower quadrant causes pain in the right lower quadrant.

Challenge 2: What's this sign called?

The diagnosis is confirmed. The patient is brought to the operating room where standard monitors are placed and he is pre-oxygenated. A rapid sequence induction is performed with cricoid pressure. A total of 2mg midazolam, 150mcg fentanyl, 150mg propofol, and 100mg succinylcholine is administered. He is an easy intubation. A peripheral nerve stimulator is used to see when he regains neuromuscular function; however, no twitches come back. In fact, the whole operation is performed without any additional neuromuscular blockade. At the end of the surgery, the patient remains paralyzed and does not spontaneously ventilate. He is brought to the ICU. Six hours after induction, he begins to regain muscle function. He has an uneventful discharge two days later.

Challenge 3: You've done 3200 cases where this hasn't happened. What's the diagnosis? (ie. the prevalence of this disease is 1/3200).


Anonymous said...

2:Blumberg sign
3:pseudocholinesterase deficiency

Craig Chen said...

well played!

The point described is McBurney’s point; the sign elicited is Rovsing’s sign. The disease described here (other than acute appendicitis) is pseudocholinesterase deficiency. Succinylcholine, a rapid depolarizing muscle relaxant, is metabolized by plasma cholinesterases and normally has a duration of action of around 8 minutes. However, in patients who have a homozygous deficiency of the metabolizing enzyme, the effect can persist for 3-8 hours.

Source: UpToDate.