What can bedside ultrasound reveal about this 22-year-old’s mysterious lower chest pain?

A 22-year-old G4P2 female is brought to the emergency department by her boyfriend for pleuritic right sided lower chest pain that she has had for approximately 18 hours. The pain is in the low anterior right side of the chest and radiates to the scapula and upper abdomen. It has been constant, but is not associated with nausea, vomiting, fever, chills, diarrhea or shortness of breath. Initially she was able to obtain partial relief with ibuprofen, but now it is not helping at all. She also denies any missed periods, bleeding, discharge or dysuria. She has been with her current partner for about 8 weeks and uses condoms for contraception, but is also on “the pill.”

On exam she appears to be in mild distress and has normal vital signs. Pertinent findings are splinting during maximal inspiration and right-upper quadrant abdominal tenderness. Pertinent negatives are anicteric sclera, clear lungs and lack of tenderness elsewhere on her abdomen and back.
Since the presentation is not really “textbook” for anything and you are worried she may have a pulmonary issue going on, you decide to do your best to avoid unnecessary advanced imaging by starting with a CBC, CMP, lipase, serum beta HCG, D-dimer, UA and a chest x-ray. After confirming that the boyfriend is driving home and they are not going by bus, you also order your favorite opiate to keep her comfortable while waiting for results.

Unfortunately or fortunately, the chest x-ray and all the labs are normal except for the D-dimer, which is elevated at 2000 (normal <250). Based on the high D-dimer, PE jumps to the top of your differential diagnosis, though you find it odd when you confirm she did not have a PE with any of her prior pregnancies, including two that went to term. You decide that since she is young and the chest x-ray is negative and you are not worried about an aortic dissection or an occult pneumonia that a V/Q scan is preferred over a CT. After all, a V/Q scan exposes the patient to a fraction of the radiation of a CT angio and there is no contrast dye involved.

Unfortunately for you (but fortunately for the patient), the V/Q scan is normal and after three and a half hours in the ED, you still have no diagnosis. Is it possible that this could be an atypical presentation for a gallstone? Eighteen hours of continuous pain with normal LFTs suggests otherwise. But rather than risk spending two more hours and who knows how much money on a formal ultrasound from radiology, you decide to take a look yourself first to see if it is really necessary.

The image at right graces your screen. What does it show? Is this what you expected to find? Does this ultrasound image make sense with the presentation?

Is this image what you expected? Discussion on next page.



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