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“Nothing in medicine is black and white,” you hear your colleague explain to one of the rotating medical students. She looks perplexed as he goes on to explain that there is an “art” to medicine and just because she learned how to evaluate and manage a certain type of patient presentation one way, doesn’t mean there aren’t other “right” ways to do it. The overeager medical student has her mouth half-open to retort back in response, when she sees you out of the corner of her eye subtly shaking your head to warn her to stop before she puts her foot in her mouth. You decide this would be a good opportunity to ask her to follow one of your senior residents as he gets ready to perform a bedside aorta ultrasound on another patient in the department.
The patient who needs the scan is a 56-year-old otherwise healthy female who presented to the ED with a chief complaint of “severe abdominal pain” after she finished lifting boxes of heavy books at her job the day before. She states her pain is worse with movement and is better when she lies still. She has never had pain like this before, and today, it is 10 out of 10 in severity. The pain is described as sharp and tearing, but it does not radiate to her chest or back. She has no other associated symptoms, and she has tried Ibuprofen without any relief.
Her vital signs are all completely within normal limits and her physical exam is only remarkable for tenderness to palpation over her left rectus muscles, and a seemingly pulsatile aorta palpable through her thin abdominal wall. She has no rebound or guarding on abdominal exam, and she has no other abnormal findings. Given her symptoms and her palpable aorta, your senior resident decides it would be prudent to do a quick scan of her aorta to make sure nothing catastrophic is imminent.
Your resident, with the medical student in tow, places the curvilinear probe on the patient’s abdomen, just below the subxiphoid process and obtains the following image (top). After he scans through the aorta in this plane, he rotates the probe so that the indicator is pointing towards the patient’s head and obtains this image (bottom).
What do you see on the images? Do you have an explanation for the patient’s abdominal pain? Conclusion on NEXT page