Here is a case that may keep you guessing. One for the US nerds. Here we go:
25 year old tourist – visiting the town, she has been backpacking for 6 months and the history is a little vague… but basically she thinks she may have had a miscarriage about 5 months ago.
She had a positive pregnancy test and two weeks later developed pain and PV bleeding. Didn’t see a doctor as she had no travel insurance… the pain settled and she thinks she may have passed some large clots – anyway the symptoms settled and she carried on her travels. No imaging was done.
Fast forward to now – 5 months later.
The history is of 24 hours of lower ado pain. The pain started in the left iliac fossa. Was well localised but has since become more generalised – on examination she is guarding and has clear peritonism across the lower belly. Certainly she is more tender on the left. She is febrile (39.8 C = 103.6 F), tachycardia 110 and has a BP of 90/60. She denies any recent PV loss, discharge or urinary symptoms. Her bowels were OK until yesterday – no motion since the pain started. A VBG shows a mild, compensated metabolic acidosis, normal lactate.
He UA shows some pyuria but no nitrites. And the B-hCG is….. [drum roll] .. negative.
So in summary – a 25 yo lady who may have had a spontaneous miscarriage 5 months ago now presents with a sepsis picture, left iliac fossa pain and peritonism. We need a scan! So I will show you a series of 6 TV US images now and let you interpret them… here we go. [I have added captions to orient you if you are not familiar with TV scan which can look a bit weird to the uninitiated ]
I think I will let this case linger here for a few days. Would really love to hear your thoughts on these images, the possible diagnoses and where to next!
Of course I will tell you what the final outcome and diagnosis was – but first lets see what you think of these images in this scenario.
Comments please. Are you a super sleuth with a scanner?
And so what happened in this case? What was the diagnosis?
After some fluid resuscitation and empirical antibiotics we headed off to the OT. Gynae started with a laparoscope – which showed: – a lot of purulent fluid – a long inflamed appendix which was adherent to theft anterior pelvic peritoneum, wrapped in omentum. – the appendix had a terminal abscess which contained a sac of frank pus in a strange casing! – Presumably a partially walled off appendix abscess in an odd location. Moral of the story: an unusual appearance of a common disease is commoner than the usual appearance of a rare disease ! The pregnancy was “noise” unhelpful clinical data
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact