Case 21

38yo G1P0 8 week pregnant female with previously confirmed IUP who presents after rapid response in the occupational therapy department.  She described feeling abdominal pain and lightheadedness, and then passed out for several seconds.  There was no seizure activity, but she did have urinary incontinence.  At the time of the exam, she was c/o crampy abdominal pain and back and right shoulder pain.

PMHx: none
PSHx: laparoscopic myomectomy for 11 fibroids

REVIEW OF SYSTEMS:

CONSTITUTIONAL: (+) general weakness
NEURO: (+) lightheadedness, (-) headache
CARDIOVASCULAR: All Negative.
GASTROINTESTINAL: (+) pain, Oral Intake: Within normal limits. Nausea: Patient has severe nausea. Vomiting Episodes: Negative. Bowel Movements: Negative.
GENITOURINARY: All Negative.
GYNECOLOGIC: (+) pregnant, Last menstrual period: 01/29/2014.
MUSCULOSKELETAL: (+) back pain, right shoulder pain
INTEGUMENTARY: All Negative 

EXAM 

V: T 97.7F P 78  RR 20  BP 101/51  O2 100% on 2lnc  

CONSTITUTIONAL: The patient is alert and in no apparent distress. Appears WDWN. 
NEURO: Oriented x 3. Motor/Sensory: Weakness noted on exam. 
GI/ABDOMEN: Tender to palpation in all quadrants. +guarding.  No organomegaly or pulsatile mass. Normal bowel sounds.
MUSCULOSKELETAL/EXTREMITIES: Normal ROM. 
RESPIRATORY: Breath sounds clear, no distress present, no wheezing rales, rhonchi or tachypnea. Normal rate and effort. 
INTEGUMENTARY: Pale. Cool and diaphoretic to touch. 
EYES: PERRL
HEME/LYMPH: No adenopathy, no palpable or tender nodes.

 

Questions:

Figure 1

Q1. What do you see in the picture?

Q2. How much free fluid in the abdomen must be presents before showing up on ultrasound?

Figure 2

Q3. What is your differential diagnosis for this patient, based on this image?  What do you see?

A1. Free fluid

A2. 250cc

A3. Uterine rupture