You are midway through an extremely busy overnight shift when you go in to see a 24-year-old female who has been waiting four and a half hours in the waiting room. You introduce yourself and apologize for the wait, hoping to improve a challenging Press-Ganey situation. During the history, she states she was feeling fine until around 10pm when she suddenly developed abdominal pain and “bloating”. She describes the pain as generalized, but mentions that it feels more severe around the edges of her abdomen, in the suprapubic area, and at both costal margins. The upper abdominal pain is most severe in the midline and is worse when she breathes in or presses on it. It also radiates into her neck, shoulders and chest. She did have one episode of vomiting and has had three episodes of diarrhea, but all were without any signs of blood. She denies fever, dysuria, vaginal discharge and any other systemic complaints.

She is otherwise healthy with no significant past medical or surgical history. Her only medication is a birth control pill. She is sexually active with one male partner who has accompanied her to the ED. Her review of systems is essentially negative with the exception of some very mild dyspnea.

On exam her vital signs are all within normal limits. Her skin is warm and dry and her head and neck exam are completely normal. Her lungs are clear and her heart sounds are unremarkable. Her abdominal exam is notable for diffuse mild tenderness and mild voluntary guarding but no rebound. There is no focal area of tenderness. Her legs are without swelling, chords or erythema. She politely refuses the pelvic exam and states she just saw her gynecologist last week for her annual check up.

Due to the protean nature of the patient’s complaints, and the fact that you are swamped, you decide to take more of a “shotgun approach” to her diagnostic testing. You have a feeling that “something just ain’t right,” even though you can’t put your finger on exactly what the problem is. You decide that’s it’s better to be comprehensive than take the risk of missing something big. An EKG done for the chest pain shows a normal sinus rhythm at a rate of 75 without any ischemic changes or evidence of strain. A chest X-ray was also done and was read as normal. Her pregnancy test comes back negative, as does the metabolic panel, LFTs and lipase. Her urinalysis appears positive with 44 white cells and 1+ bacteria and her CBC is normal except for a white count of 13. The D-dimer eventually returns elevated at 385, above the 250 cutoff in the lab.

By the time all of these tests are back and you do your re-evaluation, you are getting ready to sign out to the morning doctor. You have already tried Maalox for the upper abdominal pain and morphine for the lower pain, neither of which helped. You order a VQ scan secondary to the elevated D-dimer. You figure it has a lot less radiation than a CT scan and with a normal chest X-ray you should not end up with an indeterminant result. But how do you explain the diarrhea? How about the UTI in a young woman with no dysuria or flank pain or tenderness? And furthermore, you shouldn’t have pain and tenderness in the lower abdomen from a PE. What is going on here? You want to make some sort of contingency plan so your relief doesn’t have to get too involved in the case if the VQ comes back negative. You don’t want to order an unnecessary CT scan in someone who is so low risk, but you just get an uneasy feeling about everything. Then you remember the one symptom among many that she had mentioned, which might be important: “Bloating.”

Bloating is rarely a red flag for anything serious. The differential diagnosis usually includes the five “F’s”: Fat – no emergency, flatus – no emergency unless it’s a bowel obstruction, fetus – you’ve ruled that out, feces – no emergency, and fluid – she certainly has no liver disease. But then you think about the other type of fluid – BLOOD.

You certainly don’t want to miss that, but with no trauma and with normal vital signs, a normal hemoglobin and a negative pregnancy test, it’s pretty unlikely. However you decide to do a quick check of the pelvis and of Morrison’s pouch with the ultrasound machine before you’re ready for sign-outs. Below are two ultrasound images. What do they show? What changes in management should you make before you sign out?

What changes in management should you make before sign out? See NEXT page for case conclusion.