DIAGNOSING OVARIAN TORSION IN THE EMERGENCY DEPARTMENT: A CASE REPORT AND LITERATURE REVIEW Diagnosing acute abdomen in emergency department setting, especially in women of childbearing age, is challenging. The patient may present with non-specific complaints. We were presented with a case of a 28-year-old lady with no known medical illness complaining of sudden onset left-sided abdominal pain. Multiple analgesics were given, but her pain persisted. Bedside ultrasonography was performed and noted a multiloculated cyst over the left ovary, with the largest measuring 4 x 4 cm. She then underwent laparoscopic left salpingo-oophorectomy, revealing an engorged, gangrenous left fallopian tube and the left ovarian cyst was twisted three times. Histopathological examination confirmed a left ovarian haemorrhagic twisted ovarian cyst with a paratubal cyst. This case concludes that acute abdominal pain in women of childbearing age requires prompt and thorough investigation. Clinicians should consider several potential diagnoses, including ovarian torsion.

POSTPARTUM PITUITARY APOPLEXY: A CASE REPORT Background: Postpartum pituitary apoplexy is an extremely rare neurological emergency. It may present with sudden onset of headache, vomiting, nausea and visual disturbances. This potentially life-threatening emergency requires a high index of suspicion from the attending clinician. Postpartum pituitary apoplexy was challenging to diagnose because of its symptoms that overlapped with multiple conditions. There are limited number of case reports on postpartum pituitary apoplexy. Case presentation: We present a case of a 30-year-old multipara with gestational diabetes mellitus presented with on and off headache since 37 weeks period of gestation. Her complaint was not investigated by medical personnel during her routine antenatal follow-up until she had a normal delivery. Subsequently, she developed diplopia, nauseated and vomiting episodes post-delivery but she only came to seek treatment in our emergency department on day 12 post-partum as symptoms are not resolving. Initial Contrast Enhanced Computed Tomography (CECT) of Brain revealed enhancing sellar lesion causing widening of pituitary fossa which then she was scheduled for Magnetic Resonance Imaging (MRI). MRI brain revealed lobulated sellar and suprasellar mass with mass effect to optic chiasm and she underwent endoscopic endonasal transsphenoidal excision of tumour. Post operatively, her vision improved and she was discharged subsequently with oral hormonal supplements. Conclusion: Diagnosis of pituitary apoplexy should be suspected whenever headache and neurological deficits are present although it is an extreme rare condition.

DR, I CAN’T MOVE MY LEG! A CASE REPORT OF AORTIC DISSECTION Aortic dissection, a condition where the aorta tears, is the most frequently occurring life-threatening condition affecting the aorta, happening 2-3 times more often than the rupture of the abdominal aorta. If left untreated, 33% of patients die within 24 hours, and 50% die within 48 hours. As a result, early identification and management of the condition are critical in determining patient outcomes. We highlight a case of atypical presentation of aortic dissection in which the patient demonstrated bilateral lower limb weakness without any pain. We illustrate the vital role played by point-of-care ultrasound (POCUS) echocardiography in diagnosing the condition.

PULMONARY AND SPINAL TUBERCULOSIS IN AN 8-YEAR-OLD BOY: A CASE REPORT Tuberculosis in children is difficult to diagnose. We report a case of an immunocompetent child with persistent back pain and kyphotic deformity, without respiratory symptoms, and no contact with tuberculosis patients. Imaging shows evidence of thoracic vertebral destruction and dense consolidation in the right upper lobe. Tuberculin skin test, Quantiferon TB Gold, and Xpert MTB/RIF Ultra yielded positive results for Mycobacterium tuberculosis infection. The patient was started on and completed one year of antituberculosis therapy, with recovery shown in chest radiograph and a reduction in the static kyphosis angle.

TRACHEA INJURY IN A POLYTRAUMA PATIENT WITH AN INTRATHORACIC MIGRATION OF FOREIGN BODIES Traumatic airway injuries with intrathoracic foreign body migration are rare but can be severe and life-threatening. Prompt clinical suspicion is crucial to secure the airway and prevent further respiratory distress. Imaging is important in depicting the nature of the injury and its possible complications. We are reporting the case of a 26-year-old motorcyclist who was involved in a high-velocity road traffic accident and had extensive polytrauma with an airway injury. He was intubated and required an urgent thoracostomy for the pneumothorax. Computed tomography revealed trachea injury with intrathoracic and mediastinal foreign body migration. The patient was planned for a thoracotomy or video-assisted thoracoscopic surgery (VATS) approach for the removal of the foreign bodies. However, his condition gradually deteriorated, and he passed away due to a severe head injury.

Ovarian cysts are rare in children. Their common presentation is acute abdomen, which can be a life-threatening event that needs emergent investigation and intervention. Herein, we report a gynaecological case of a twisted ovarian cyst in an 11-year-old girl who presented to the emergency department with sudden-onset generalised abdominal pain. Multiple strong analgesics were prescribed, and pain-controlled analgesia was then started. Abdominal ultrasound revealed a left adnexal mass, and abdominal computed tomography showed a non-enhancing soft tissue tumour with multiple cystic components in the pouch of Douglas. The patient underwent emergency laparotomy, which revealed a gangrenous left ovarian mass measuring 9×5 cm that was twisted five times. Histopathology showed extensive haemorrhagic infarction with no remnant of viable tissue, consistent with a twisted ovary. It was challenging to determine the origin of the pain in this patient, as thorough examination could not be performed because she was in severe pain. Abdominal ultrasound helps guide diagnosis, as a gynaecological cause is rare in premenarchal children. A vigilant assessment is important to avoid delays in diagnosis and emergency intervention.
Ovarian Cysts ; Abdomen ; Child

Introduction: Emergency department (ED) plays a main role in the initial management of patients who are critically ill. These patients require intra-hospital transfer for continuation of care. Adverse events can occur during this short duration and the distance of intra -hospital transfer. The aims of this study were to determine the incidence of adverse events during intrahospital transfer from ED and to determine the factors associated. Methodology: This was a cross-sectional observational study done from November 2017 until December 2017 at ED Hospital Sultan Abdul Halim (HSAH), a 650-bedded tertiary hospital in the state of Kedah. All patients that were triaged to red zone, age 18 years and above, and involved in intra-hospital transfer to critical coronary unit, intensive care unit and wards were included. All cases were documented in proforma by the accompanying staff. Results: Among the 170 critically ill patients, only 29 patients (17.1%) experienced adverse events during intra-hospital transfer. The adverse events seen were hypotension (12.4%), desaturation (3.5%) and dislodged peripheral line (2.4%). Cardiorespiratory related diagnosis was the commonest presentation. Intra-hospital transfer during morning shift and evening shift has 79.5% (b=-1.59, OR=0.21, 95% CI: 0.06, 0.69, p=0.011) and 75.6% ((b=-1.41, OR=0.24, 95% CI: 0.08, 0.73, p=0.012) lesser odds of experiencing adverse events compare to night shift. Patients with vasopressor/inotropes had 9 times higher odds of experiencing adverse events during transportation, compared to patients with no vasopressor/inotropes (b=2.27, OR=9.70, 95% CI: 3.39, 27.72, p<0.001). Conclusions: Critical care patients who are involved in intrahospital transfer were at risk of adverse events such as hypotension, desaturation and dislodge peripheral line. Risk identification and maintaining level of care is important to minimize the adverse events during transfer. Patients had higher rates of adverse events if they were transferred during night shifts and on inotropic/vasopressor support