Case+6+-+Pregnant+and+confused

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Earlier this spring a 35 y/o female G2P1 presented with mother to hospital with complaint of confusion. Her mother states that she believes her daughter may be pregnant as she has not had a period in over at least 2 months. Over the last week mother has been concerned as her daughter has been ‘talking about strange topics’ and in the last 3 days has even been slurring her speech. This is very uncharacteristic for her daughter with no prior episodes. She does have a history of a seizure disorder with occasional post-ictal confusion, however there have no recent seizures in last several months. Patient is taking carbamazepine for her seizure disorder. Mother denies any recent fevers, no vomiting or diarrhea, no observed rashes. She is walking with no balance problems. She does state that daughter has suffered from significant leg swelling in the last several weeks as well. No head trauma history. Denies any overt pain.

PMHx: history of seizure disorder on carbamazepine with 1 seizure in the last month. No other hospital visits

OBHx: 6 year old daughter with unremarkable pregnancy, vaginal delivery

Social history: Lives with mother and daughter 4 hour’s journey from hospital. They are subsistence farmers and are afraid of poor crop yield while be away from the crops at the hospital. Does not consume alcohol, smoke, or use any recreational substances.

PE: Vitals: P 80 BP 110/70 RR 15 O2sat: 98% Temp: 36.8 Gen: Awake and alert with slow movements. A and O x 1 (only to self). Believes she is in a different town and unaware of the season. Markedly slurred and slow speech. No observable tremors. HEENT: sclera anicteric, PERRL, mmm. Neck: no neck stiffness appreciate. No JVD. Pulm: CTAB, no crackles or wheezing CV: nl S1 and S2, no m/r/g Abd: distended but soft, + bs. Significant fluid wave. Palpable suprapubic mass measuring to 16 weeks. Distant but likely splenomegaly measured to 4cm below the left costal margin. No palpable liver, with no abdominal pain palpated. Ext: gross 3+ peripheral edema Neuro: CN II – XII intact, patient able, tohugh slowly, to comply to neuro exam. Moving all extremities with strength 5/5 in all fields, with no sensory deficits. Mild twitch asterixis noted.

Upon consultation the following labs had been resulted: Hgb 9.5 MCV 90 WBC: 4.2 Normal diff Platelets: 40 MRDT: negative HIV test: negative Urine dipstick: no RBCs, no nitrates or leuk est, no protein

As labs can take days to return at times, we elect to continue the work-up with POC ultrasound.

You obtain the following hepatorenal window:

Splenorenal window:

Transverse pelvic view:

What are your findings in each of the windows?

What diagnosis do these ultrasound findings combined with above clinical context suggest?