Left Lower Ribs Research Articles

Chest Wall Pain In A Marathon Runner

HISTORY: A 39-year old male marathon runner presented with 1 year of left-sided anterolateral chest wall pain at ribs 10 and 11. Pain started insidiously, without trauma or other inciting incident. Pain primarily occurred with running, and typically worsened as his pace increased. Lifting weights, deep breathing, and prolonged sitting did not exacerbate pain. He denied cough, dyspnea, or wheezing. PHYSICAL EXAMINATION: Normal chest wall expansion. No visual deformity along the ribs or costal cartilage. Tenderness to palpation was noted along the left 10th and 11th ribs and intercostal muscle anterior to the mid-axillary line. No tenderness at adjacent segments or at the same segment on the contralateral chest wall. Mild left-sided chest wall pain with leftward thoracic rotation. DIFFERENTIAL DIAGNOSIS: 1. Costochondritis 2. Tietze syndrome 3. Slipping rib syndrome 4. Thoracic radiculitis 5. Pleurisy TESTS AND RESULTS: MRI Chest Wall: Focal thickening and edema along left lower ribs at region of pain, with surrounding soft tissue swelling. No pleural or pericardial effusion. No bone marrow edema within visualized osseous structures. Ultrasound Chest Wall: Significant signal impedance and focal thickening noted along the intercostal muscle of the left 10th and 11th ribs at the area of maximal tenderness along the anterolateral chest wall. No comparable signal changes are observed at adjacent segment levels or the same segment on the contralateral chest wall. FINAL/WORKING DIAGNOSIS: 1. Tietze syndrome TREATMENT AND OUTCOMES: 1. Performed corticosteroid/lidocaine injection to left 10th-11th rib intercostal muscle under ultrasound guidance 2. Pain diary for 6 hours immediately following injection 3. Routine marathon training as tolerated 4. Ice as needed after running 5. Pain resolved following injection. Inflammation and intercostal muscle hypertrophy resolved on repeat ultrasound 2 months later. 6. Patient completed Berlin and Chicago Marathons in 2019

Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) or Stevens - Johnson syndrome (SJS): Does the Name Matter!

The case is of 23-year-old Caucasian male who fell from 30 feet height in a suicidal attempt. He sustained multiple orthopedic fractures including hips, left lower ribs, and right radius at the elbow. He had multiple orthopedic surgeries with fixation of his fractures including pins, plates and screes. He presented to the hospital with fever, tachycardia, and malaise. He was discharged initially to long-term acute care (LTAC) for continued recovery. After 3 weeks in the LTAC he developed pinhole infection of his hip and right forearm which was reported methicillin resistant staphylococcal infection (MRSA) positive and was started on Vancomycin.

Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) or Stevens-Johnson Syndrome (SJS): Does the Name Matter!

The case is of 23-year-old Caucasian male who fell from 30 feet height in a suicidal attempt. He sustained multiple orthopedic fractures including hips, left lower ribs, and right radius at the elbow. He had multiple orthopedic surgeries with fixation of his fractures including pins, plates and screes. He presented to the hospital with fever, tachycardia, and malaise. He was discharged initially to long-term acute care (LTAC) for continued recovery. After 3 weeks in the LTAC he developed pinhole infection of his hip and right forearm which was reported methicillin resistant staphylococcal infection (MRSA) positive and was started on Vancomycin.

Contemplating Callouses

When did I become so calloused? Was it when I began clinical rotations in medical school and noticed that some of my patient's chief complaints were problems that I dealt with on a daily basis? Was it when internship commenced and the weight of my newfound responsibilities, coupled with the stress of an overbearing schedule, numbed my senses? Was it before I even stepped into the patient's room and the nurses informed me that the patient I was soon to evaluate was “just drug seeking?” I'm not completely cognizant of when the transformation occurred. But, at some point the hallowed charge of healing the ailing became less of a calling and more of an onus. This became evident to me one morning not long ago. My day shift commenced as most others do. I began evaluating and treating the infirm, when one patient's chief complaint caught my attention: “Pain on the left side after patient tripped and fell against her baby's crib.” This seemed to be a particularly innocuous means of sustaining a serious injury. I was further underwhelmed with her injury mechanism after reviewing her completely normal vital signs listed on the triage note. Upon entering her exam room I noticed the pajamas she was still wearing and could not help but imagine her tripping on the rug in her infant's bedroom and stumbling against his crib. The history I elicited from her depicted the story I had just imagined, with no new ominous details. Her intermittent winces and the cry she released when I palpated her left lower ribs caused me to ponder the degree of pain she was experiencing, as well as if she exhibited a propensity for theatrics. I purposed to give her the benefit of the doubt and ordered x-rays, as well as opioid analgesia. Shortly thereafter, I was relieved to find that the analgesic I had administered nearly ameliorated her pain. I reviewed her x-rays, which were normal. “No surprise there,” I thought to myself. I reentered the patient's room to reassure her, only to find her in more pain. In addition, her systolic blood pressure had dropped to the upper 90s, a change of nearly 20 mm Hg. Labs and a computed tomography (CT) scan were ordered, while intravenous fluids were initiated. Upon review of the completed CT scan, I was horrified and astounded to find extravasation of contrast into her abdomen, extruding from her spleen. Within minutes, the radiologist called confirming my fears: “Severe splenic laceration, probably at least grade III,” he stated. “Could a fall against a crib really do that?” I pondered. I hurried to the patient's room to update her and found that her systolic blood pressure now hovered in the 70s. I gave orders to administer blood immediately and initiated transfer to the local area trauma center. Before long, the patient had been transported out of the ED. Upon arrival to the trauma center, the patient was conveyed directly from the helicopter to the operative suite, as her mentation had deteriorated and her blood pressure continued to decline. After finding a complete transection of her spleen, the patient underwent splenectomy. She stabilized and spent the proceeding days in the hospital recuperating. I later ruminated as to why I initially had not taken her complaint seriously? Was it that I had evaluated thousands of patients with comparably benign mechanisms of injury, whose hospital courses had culminated in nothing more than discharge prescriptions for analgesics? Was it that I absurdly believed I would invariably be able to identify all patients who bore critical illnesses? Or was it that I had simply become too calloused to remain objectively astute? Likely, to a degree, all three reasons were to blame. While harrowing, and nearly tragic, I am grateful for this case as it helped readjust my perspective on patient care. In addition, it reminded me that every patient is unique and that with each new patient, you never know what you are going to get.

Cervicovaginal tuberculosis in a postmenopausal woman

age, and was firm and mobile. Fornices were free and nontender. The cul-de-sac and rectalmucosawere free of disease on rectal examination. Preliminary diagnosis was elephantiasis of the vulva with high degree of suspicion for carcinoma. The patient's white blood cell count was 7700 cells per mm, with 62% neutrophils, 29% lymphocytes, 3% monocytes, 9% eosinophils; hemoglobin level was 9.3 g/dL, platelet count 393×1000 mm, erythrocyte sedimentation rate 20 mm/h, and absolute eosinophil count 693 /μL. On peripheral smear, nomicrofilaria was seen. Liver and renal function tests were within normal limits. Chest X-ray revealed fracture of the seventh left rib, crowded left lower ribs, haziness along the left lateral wall, blunted cardiophrenic angle, pleural thickening, and mild cardiomegaly. An HIV antibody test was negative. PAP smear cytology was atrophic with inflammation. Because the patient had compromised pulmonary function, general anesthesia wasnot contemplated and vulvalmass excisionwasperformed successfully under local anesthesia. Hemostasis was secured using Vicryl 2-0 sutures (Ethicon, Somerville, NJ, USA). Duration of surgery was 40 minutes with a blood loss of 100–120 mL. An indwelling urinary catheter and vulval drain were retained for 48 hours after surgery. The patient received 200 mg of oral cefotaxim twice per day for 2 weeks, along with analgesics and antacids postoperatively. The patient was discharged on postoperative day 3 in good condition. The biopsy specimen showed foci of necrotic granulomatous inflammation with focal edema and hyalinization, although the acidfast bacilli test was negative. The patient was started on antituberculosis treatment. Vulval examination on postoperative day 9 revealed minimal inflammation. There are few reported cases of vulval tuberculosis, although granuloma on vulval biopsy has been documented [1–3].

Upright posture impact on spine susceptibility in scoliosis and progression patterns of scoliotic curve

To investigate the impact of upright posture on spine susceptibility in scoliosis and scoliotic curve progression patterns. There were 3 groups designed in the experiment: bipedal rats group (n = 26), quadrupedal rats group (n = 26) and sham operation bipedal control (n = 12). Taking the advantage of bipedal rats' upright-posture simulating effect, operations were exerted with posterior central approach between scapulas. Along the spatial of erector spinae muscle and trunk muscles, left side upper (T2-3 or T3-4) and lower (T10-11 or 11 - 12) ribs were tethered with type4 thread to make asymmetrical stress and simulate a primary thoracic curve. At time of 1, 2, 3, 4, 6 and 8 weeks post-operation (PO), each group were taken dorsoventral X-ray photographs for dynamic observation on the difference of scoliosis turnover and to compare the curvature progression difference between bipedal and quadrupedal rats. Operation resulted in a primary single thoracic curve or thoracolumbar curve convex to the right in both bipedal and quadrupedal rats. At 1 - 4 weeks PO, all asymmetrical tethers became loose because of rib fracture or osteolysis at the tether sites. All scoliosis of quadrupedal rats disappeared and spine resume straight in 1 - 4 weeks later. Analogically, scoliosis disappeared in bipedal rats for those tethers loose in 1 w PO. But prolonged tethering, scoliosis progression rates increased conspicuously. 3 - 4 weeks' tether time led to irreversible scoliosis. Meanwhile, the curvature progression patterns of bipedal rats presented to be various, including the stable single thoracic curve, progressive thoracolumbar single curve and progressive double curve. These curvatures were much alike that of human idiopathic scoliosis. No scoliosis appeared in sham operation bipedal control. The upright posture increased spinal susceptibility in scoliosis; Upright posture changes the progression pattern of scoliosis, leading to variegated scoliotic morphouses during primary thoracic curve progression, while inducing curve compensation phenomenon in scoliosis.

Do doctors position defibrillation paddles correctly? Observational study

Defibrillation is necessary to restore normal sinus rhythm in a patient having a ventricular fibrillation arrest. Each minute of delay in restoring sinus rhythm increases mortality by 7-10%.1 Successful defibrillation...

Left upper quadrant increased uptake in bone imaging

A 42-YEAR-OLD female with right hilar bronchogenic carcinoma was receiving chemotherapy. Her serum calcium appeared to be 16.2 mg/dl. Chest radiographs showed that her peripheral lung fields were clear. A 99mTCMDP bone image obtained for metastatic workup revealed diffuse increased uptake in the upper halves of both lungs and in the stomach (Fig. 1) which was thought to be caused by microscopic calcium deposition in the pulmonary parenchyma and the submucosa of the stomach secondary to hypercalcemia. On a follow-up bone image (not shown) after her hypercalcemia responded to treatment, the uptake in her lungs and stomach both decreased significantly. Common: Left Lower Ribs (1) Metastatic or primary bone tumor 1 (2) Trauma 1 (3) Infection l (4) Paget's disease I

A large suprarenal tumour.

Case of a man, aged 44, who in 1940 received an injury to the left chest wall with fracture of the left lower ribs. In 1947 he attended hospital, complaining of tightness in the upper abdomen. A mass could be felt below the left costal margin, which was considered to be an enlarged spleen.

The Nursing Care of Hodgkin's Disease

to breathe. All the superficial glands could be felt, but none were very large. They were discrete and not tender. The skin showed evidence of frequent scratching. The spleen was so large that the lower border could readily be felt a hand's breadth below the left lower rib margin. It was firm and not tender. He had a fever of 102? and the blood showed a slight increase in the number of white blood corpuscles. The red blood count was 2,800,000, the hemoglobin 52 per cent. An x-ray of the chest showed a large mass of glands at the bifurcation of the trachea, evidently pressing on it and on the left main bronchus. Evidently this pressure was obstructing his breathing. An x-ray treatment over the chest made him very ill with nausea and vomiting. His condition was considered critical. During his eleven weeks' stay in the hospital Fred grew progressively worse. The dyspnea became more pronounced and he coughed a great deal, raising a little sputum. He ran irregular bouts of fever of the Pel-Ebo breathe. All the superficial glands stei type as shown in the chart. He grew pale and weak. X-ray therapy was abandoned as he did not respond to it. At the end of the eleventh week he developed a terminal bronchopneumonia and expired. A complete autopsy was performed which showed Hodgkin's disease of the superficial lymph glands and also of the mediastinal and abdominal ones. The spleen was extensively involved and showed the characteristic porphyry appearance on cut surface. The liver was slightly enlarged and was also affected. The lower trachea and left bronchus were compressed by a large mass of lymph glands, and both lungs showed patches of bronchopneumonia. Comment.-This patient did very well for a period of time and then went rapidly down hill with symptoms of mediastinal pressure, anemia, itching of the skin and fever. This is the usual course of events and places Hodgkin's disease in the class of disorders of which we do not know the cause and for which we have no cure. in type as shown in the chart. He