When it rains, it pours. You and your overnight team of residents have just finished some of the most challenging tasks in emergency medicine. Through a translator, you had to tell the lady in room two that her abdominal CT shows a pancreatic mass that will “need further work-up.” You were asked by family members to reverse the DNR and aggressively resuscitate an elderly hospice patient in dire straits, and, to top it off, the two-year-old hit-and-run you just saw in the trauma bay had non-survivable injuries. You are definitely looking forward to the traditional early morning debriefing at the local breakfast diner after the black cloud clears.

You breathe a small sigh of relief when your senior resident begins presenting his next case to you. The patient is a 17-year-old G1P0 who found out she was pregnant via a home pregnancy test last month. She hasn’t seen a doctor about her “condition” yet. She presents to the ED at 6 AM because she has been vomiting all night and can’t sleep. She’s been feeling nauseated all week long, and now notes that things are definitely getting worse. She denies any other symptoms such as bleeding, pain or fever. Other than looking a bit peaked, your resident feels that she’s pretty healthy and stable. She’s a bit tachycardic with a pulse of 108, but her vital signs are otherwise normal. Your resident ordered for a peripheral IV to be placed, a rainbow of tubes to be drawn and held, a liter of normal saline and a dose of ondansetron. He ordered a urinalysis off the straight catheterization he performed during her pelvic exam. Now, all he needs is for you to help him with the endovaginal ultrasound he is preparing to perform at the bedside.

As your resident is setting up the machine and the archiving system, you silently thank the powers that be for giving you at least one straightforward case for the night. The patient and her boyfriend are pleasant and thankful, and your resident is about to complete the final pelvic ultrasound he needs to fulfill his credentialing requirements. He carefully explains to them that he is going to perform a limited study at this time and that at some point a more comprehensive scan will need to be ordered through the radiology department.

You have your resident start with a transabdominal scan with the 3.5 MHz curvilinear probe so you can map out the pelvic structures and get a sense of what lies ahead. After obtaining a few images, you exchange a subtle glance with your resident and see that he has his best poker face on, too. After taking a quick peek at the hepatorenal space, your resident moves on to the endovaginal scan using a 5-8MHz intracavitary transducer and obtains the following images:

click on images to enlarge


What do you see on the transverse and longitudinal views of the uterus? What do you do next?
Conclusion on next page


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