It seems like your entire shift has been non-specific abdominal pain, peppered with a few non-cardiac chest pains and some non-organic headaches that are only relieved by Dilaudid. No one feels your pain from taking care of patients that don’t really need to be in the ED in the first place, but hey, it’s job security, right? So you suck it up and grab the next chart in the to-be-seen box. The chief complaint reads “gas pains.”

 “Great.” you mutter under your breath. Then you smile, thinking that at least this patient has a somewhat original complaint and has given her condition enough thought to make a supposition about what the cause of their discomfort may be. Then, you wax sagacious, thinking to yourself that no normal person would actually come to the ED for pain that they truly thought was due to gas. You conclude that behind curtain number three you will either encounter a total moron, or a stoic individual who actually has something serious going on, but hopes that they just have gas.

You walk into the room and introduce yourself to your patient. She happens to be a 40-year-old female attorney with her husband at the bedside. She states that she ate a huge Greek salad, with a lot of onions in it, for lunch, and now she has terrible gas pains. The pain started in the supra-public area, but thereafter spread to her entire abdomen. She also feels a bit light-headed, but that is actually improving. There has been no fever, vomiting, diarrhea, cardiac or pulmonary symptoms. She is otherwise healthy with no prior medical problems or prior surgeries. Her only medication is prenatal vitamins, which she is taking because she and her husband are trying for their first child. She states that her last period was about 1 month ago. She rates her pain as “5 or 6 out of 10” and she thinks this is all gas because onions always give her gas. When asked if she ever had to see a doctor in the ED before for gas pains, she answers, “Well… no, but I wasn’t going to come here. I went to an urgent care and they referred me to you.”

On physical exam, her heart rate is 112 and her BP is 133/71. The rest of her vitals and physical exam are essentially normal, except she has involuntary guarding in all four quadrants of her abdomen. While you percuss about, you ask if it hurts, and she answers, “not that bad” meanwhile wincing each time you press. It’s not your first rodeo, so you know you need to be extra cautious with a stoic patient like this. Frequent flyers in the ED who have multiple visits, but never seem to have an actual acute medical condition may eventually burn you if you let your guard down. They tend to be overly dramatic and helped only by opiates or benzodiazepines. However, it is with the stoic patient that you are most likely to miss or delay an important diagnosis. If they’ve never been to your ED before for the current complaint or, even more telling, they have their hospital gown on backwards, beware! These are the ones in which you have to assume the worst-case scenario until proven otherwise.

This is exactly what you do. Thinking “ruptured ectopic,” you are glad to have a patient that you may actually be able to help. You order labs, a type & cross and some fentanyl. Then, you briskly wheel over the portable ultrasound machine and take the two images shown at below.



What part of the body is each image from, and what does it show? Is your suspicion supported? What should be your next move, and what other test results do you need to wait for before proceeding?

See NEXT page for case conclusion.


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