Clinical Case 04

26 Jul

The case

A 30 year old female with very poor english is brought to the ED following a syncopal episode at home. This was brief and with rapid recovery. On questioning she appears to have some mild abdominal pain but language limits any further history. Vital signs are normal but she looks pale and slightly diaphoretic

What are you worried about?

the obvious diagnosis is a ruptured ectopic pregnancy but given the language barrier and lack of history  the differential remains quite broad. You need to rapidly narrow the differential here without any useful history

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She becomes more diaphoretic and heart rate spikes to 110 bpm. You grab your trusty USS machine and obtain the following images

What do the images show

clinical case 03.1
RUQ

clinical case 03.2
LUQ

clinical case 03.3
Pelvis Sagittal

 

there is a large volume of free fluid in the abdomen, both in the pelvis and in the upper quadrants. note the Fluid is in Morisson’s punch in the RUQ and superior to the spleen (not the splenorenal recess) which is the normal distribution for the LUQ.

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What is your differential diagnosis now?

ectopic rightly remains top of your list but effectively anything causing free fluid in the abdomen from occult trauma to a perf DU to a ruptured ovarian cyst  may cause this appearance. Certainly in the unstable patient theatre is likely the right answer to all of these. However good luck finding a surgeon to take the patient to theatre with this little info. 

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What do you need to seal the diagnosis here?

an HCG – serum, urine doesn’t really matter

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How are you going to get that HCG?

hmmm. Wait for urine… what is this paediatrics?!? We want urine from a hypovolemic hypotensive patient – good luck with that. And even when you get it maybe you have to send it to the lab to get it tested. It’s probably easier to get a serum sample but then there’s still the lab wait

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Is there another way?

turns out… you can put blood on a urine HCG dipstick and get a reliable result. And it also turns out that you’re not just making up some crazy bonkers new test – it’s actually been studied before [H/T aliem.com]

  • Fromm C, Likourezos A, Haines L, Khan AN, Williams J, Berezow J. Substituting Whole Blood for Urine in a Bedside Pregnancy Test. J Emerg Med. 2011 Aug 27. Pubmed .
  • Habbousche JP, Walker G. Novel use of a urine pregnancy test using whole blood. Am J Emerg Med. 2011 Sep;29(7):840.e3-4. Pubmed .

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