QA of the Month: July 2013

Epigastric Pain and Vomiting

Case

Case – 25 year old female with CLL in remission but on chemotherapy, and history of pulmonary embolus, presents to the ED with chest pain, epigastric pains, nausea and vomiting for 2 weeks, worse with eating. 

Vitals

HR 90 RR 18 BP 119/68   T 97.9

Physical Exam

PE – Remarkable only for mild epigastric tenderness, but otherwise within normal limits 

Per chart, the DDx considered was – Pulmonary embolus, Pericarditis, Gallbladder disease, Gastric outlet syndrome. Work up included, blood work, including D-Dimer and Chest x-ray – both resulted and unremarkable. Fortunately, the Ultrasound team was in the ED doing a scanning shift, and performed US applications to evaluate abdominal pain after speaking with the providers. 

The Gallbladder scan revealed a normal gallbladder without stones or signs of cholecystitis. They continued with a FAST and trans abdominal pelvis studies. The FAST study did not reveal any free fluid. The trans abdominal pelvis study showed the following images.

This shows a live intrauterine pregnancy measuring about 8 weeks 6 days gestational age with fetal heart rate of 154 beats per minute. The patient and the ED providers were not aware of this pregnancy. There was no urine pregnancy test sent. The patient reported using condoms regularly, and was well aware of the risks of getting pregnant while on chemotherapy. With this finding, the ED management and outpatient management clearly changed, simply because someone took a look with the ultrasound! The patient was given follow up instructions with her OBGYN. 

Transabdominal Pelvis Ultrasound Tips and Tricks

When performing a TA Pelvis study on a female at the bedside the main questions you want answered are: 

  1. Is the patient pregnant? If so, is it an intra uterine pregnancy (IUP)?
  2. If you see an IUP, then are there more than one? Do you see a heart beat and what is its rate?
  3. Do you see free fluid?
  4. Is there any obvious pathology noted in /around the adnexa? Or other possible causes for pelvic pain?

A TA pelvis study should be done with a full bladder, to allow for better visualization past the bladder into the Pelvis. You can either use the phased array probe or the curvilinear probe. Evaluate the uterus in both horizontal and sagittal axes completely by fanning through the entire uterus.

Look for signs of a Gestational Sac ( - If so, is there a yolk sac? Is there a fetal pole? Is there a heartbeat?), and Irregularities within/around the uterus (– Is it homogenous? Is there a fibroid/mass? Do you see free fluid?) You then want to slide to either side, to evaluate each ovary and fan through the ovary to look for fluid filled cyst, masses, or other pathology. It is normal to have some amount of free fluid in females known as physiological free fluid, typically up to about 1/3 the length of the posterior uterine wall.

However, if the amount of free fluid is greater than 2/3 the length of the posterior uterine wall, that is a large and abnormal amount. An IUP on ultrasound is defined as an intrauterine gestational sac plus a yolk sac, or yolk sac with fetal pole and contents. A gestational sac alone is NOT an IUP, and can be a pseudosac, in the context of an ectopic pregnancy. If you see a confirmed IUP, then you want to check to see if it is a single or multiple gestations.

Next, evaluate for fetal heart rate, by visualizing the heart rate, and then using M Mode as shown above to calculate the FHR (DO NOT USE DOPPLER). Next, measure the approximate gestational age by assessing crown rump length (CRL, as shown above) in the first trimester, bi-parietal diameter (BPD) in the second or third trimester. CRL is the most accurate measurement.