“I need a breath of fresh air,” your senior resident states. He has had a pretty rough night. He missed an LP on a rather robust woman with “the worst headache of her life” and then the trauma team swooped in and “stole” his thoracotomy on a GSW that was dropped off at the ambulance door. You tell him to take all the time he needs as you turn your attention to the intern that has been patiently awaiting your emergence from the critical care bay.

Jealous that she hasn’t had a single procedure yet during the shift, your intern is eager to tell you about the next patient she saw. It sounds like a relatively straightforward case: a 72-year-old male brought in by his nursing home aide for abdominal distension. He has a history of dementia and is primarily bedridden at baseline. The patient cannot give any reliable history, but on physical exam, his otherwise thin abdomen shows obvious signs of suprapubic distension. Your intern recaps his vital signs, which include tachycardia at 120 bpm, a blood pressure of 190/86 mmHg, a respiratory rate of 20/min, and a normal temperature and O2 saturation.

“What should we be worried about?” you ask. Your intern rattles off a differential diagnosis straight out of Tintinalli. Without missing a beat, she continues to explain how she plans to rule-out the scary etiologies such as acute intraperitoneal hemorrhage or ascites, AAA, mesenteric ischemia, perforated bowel, acute cholecystitis, appendicitis, and SBO. Her initial orders are spot-on, and before you can utter another syllable, she grabs the ultrasound machine and wheels it over to the patient’s bedside. You follow a few steps behind her, and observe with pride as she performs a scan of Morrison’s pouch, followed by a quick look at the gallbladder, aorta, splenorenal space and right-lower quadrant. She gently calms the agitated patient as she slides the probe down towards his suprapubic region.


Her ultrasound image is depicted here. What do you see? What does this patient need?  Conclusion on next page


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