22 yo female presents to the ER c/o 11 days of lower abdominal pain, crampy in nature, but unrelenting. Pain is much worse when she moves, walks, bends over, or tries to walk up stairs. Denies fever but has had occasional chills. Able to keep down food, denies any dysuria. She was seen in another ER 10 days ago and diagnosed with ectopic pregnancy and given methotrexate. At day 2 post-administration of methotrexate, she was still having minimal abdominal pain with vaginal discharge so she returned to the original ER where she was given methotrexate for reevaluation. At that time she was passing small clots, and a quantitative bHCG was somewhat reduced from her initial bHCG at diagnosis of ectopic pregnancy (3700 mIU to 3500 mIU). Since it was trending in “the right direction,” she was told she would feel better in a few days and that she could follow up with her PCP. She can’t get in to she them, and she is at the point where she can barely walk without severe pain. This was her first pregnancy and she has been sexually active since being given the methotrexate. Other than still passing clots, denies other vaginal D/C.
PMH/PSH – bipolar D/O
She is a smoker and drinks occasionally – no illicit or recreational drug use.
HR – 80
O2Sat 98% RA
Pain 7/10 without movement, 10/10 with palpation or any movement involving belly
AOx3, appears very uncomfortable, cannot find a comfortable position on the stretcher, cool to touch
HEENT – WNL
Chest – RRR, no M/R/G
LS CTAB, no W/R/R
Abdomen – very TTP, (+ rebound tenderness in lower quadrants). Does have good bowel sounds. CVAT unremarkable. 10/10 pain elicited when palpating LLQ area
Vaginal – passing blood – speculum exam deferred until seen by OB
Skinis pale, cool and moist.
Rest of physical exam is non-contributory
Ok, a few things:
1) What is the most likely diagnosis?
2) What do you want to do to test for this?
3) What is the definitive treatment?
4) What argues against the most likely diagnosis?
5) Can you postulate a theory that encompasses all of the facts as presented to provide a single, unifying diagnosis?
Feel free to ask about other labs, imaging, etc – but I want you to think through this first as to what’s going on before jumping into labs, etc. This is one of those diagnoses that exam alone diagnoses. You have everything you need. I will post final picts as well, along with labs, once we get to that point.