Case+7+-+Abdominal+Pain+and+Tachycardia

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 * This is another case that was brought to our attention at the infamous morning handover. All we were told initially was there was a 24yo female sent in from an outlying clinic last night with concern for possible ectopic pregnancy. “Can you do an ultrasound?” (of note, our hospital had NO urine pregnancy tests at the time of this patient’s presentation) **

On review of her chart, you see find that she is a 24yo female, HIV positive on ART who presented to an outlying clinic the day prior due to abdominal pain. She was well until at around 5pm when she started having severe abdominal pain with any activity. She was initially seen at an outside clinic, found to be febrile to 38C with diffuse abdominal pain. MRDT was taken and found to be positive for malaria and urine pregnancy test was positive. The patient was given ceftriaxone 2g IM then sent to the District Hospital with diagnosis of acute abdomen.

At the time of our interview, we found Ms JD laying in bed. She reported continued, severe abdominal pain. She reported mild cramping for 1-2 days, then acute worsening around 5pm the evening prior to interview. She denied any pain similar, no trauma or injury. Over the course of her time in the hospital, pain began to become generalized throughout her entire abdomen. She states she was initially able walk with assistance to the clinic, but now pain exacerbated with even minimal movements in bed. Pain quite severe that exacerbated even by rolling over in bed. She also reported fevers at home x 1 day as well as 3 episodes of NBNB emesis. Last able to eat the night prior to arrival, tolerating liquids this AM, last BM on morning of interview - watery in nature. C-section is her only prior surgery. She was seen in an outside clinic 2 days prior and noted to have a fever, diagnosed with sepsis and sent home with amoxicillin-clavulanic acid without improvement.

ROS Reported amenorrhea x 2 months, also noted to have C/S in 2008 (first preg) followed by 1 successful VBAC, nonbloody, nonbilious emesis x 3 in the past 24 hrs, loose stool performed last on morning of interview, vaginal discharge.

Exam: General: laying in bed, wakes easily, NAD, though discomfort noted on minimal movement (ie turning from side to back) HEENT: pallor noted in conjunct, MM moist appearing Cardio: Rate 120, regular, no murmurs Resp: CTAB, no wheezes or crackles Abd: **//mildly distended, faint BS, diffusely tender with exquisite rebound noted in throughout - but most marked in RLQ and LLQ. Involuntary guarding noted as well.//** Ext: No edema Skin: no rashes or lesions
 * T 39.1C HR 120 RR: 22 ** BP: 95/55


 * // So, after much ado, the ultrasound comes into play and this is what you see: //**


 * // Image 1: //** Suprapubic, longitudinal orientation




 * // Image 2: //** RLQ view, longitudinal orientation


 * // Image 3: //** RUQ, hepatorenal recess


 * // Image 4: //** LUQ, splenorenal recess

What are your findings in each of the views? How does the ultrasound guide your management now?