“There is no such thing as a ‘black cloud’,” your colleague jokingly retorts. “We all get the same chances to make the diagnosis and to do what’s right.” You give him your best pseudo-evil-eye as you continue to recount the number of unfortunate cases you’ve seen with the residents this evening already. An aortic dissection in an otherwise “healthy” 40 year-old, an intracranial hemorrhage in a 23-year-old following a cocaine binge, a cervical spine fracture in a patient who drove himself to the ED two days after his car accident, and an epidural abscess in one of your department’s frequent fliers. Black cloud or not, you’ve had one heck of an interesting evening, and you don’t anticipate it becoming mundane any time soon.
You wonder if you’ve spoken too soon when your intern comes up to discuss his next case. It’s an otherwise healthy 43-year-old female who comes to the ED tonight because she is having increased right upper quadrant pain. Your intern notes that she has had intermittent pain for the past few months, but tonight it became unbearable. She thinks the pain was worse after she ate dinner, and notes that she has had fevers and chills, but never took her temperature. She denies any nausea, vomiting, or changes in her appetite, skin or urine color. Her bowel movements have been normal as well. Her exam is only remarkable for right upper quadrant tenderness to palpation, and your intern thought she had a positive Murphy’s sign. Given the story, it is no surprise to you that your rock star first-year resident has committed to a differential that includes cholelithiasis, cholecystitis, pancreatitis, gastritis, or an atypical appendicitis.
Before you let him off the hook so easily, you throw out a few critical questions:
- “Is she pregnant?”
- “Nope, she’s had a hysterectomy.”
- “Does she have an acute abdomen?”
- “Nope, it’s otherwise soft, without rebound or guarding.”
- “What did her bedside ultrasound show?”
- “I was just about to go do it…”
You smile as your intern grabs the ED ultrasound machine and heads towards the patient’s room.
A short while later, your intern returns with the ultrasound machine in tow. “Can you take a look at these images with me?” he asks with a confused look on his face. “Something just doesn’t look right.”
What did he see on his bedside scan? What do you do now? Conclusion on next page