# 279 Un femme d'un certain age
A middle-aged English-speaking foreign visitor is brought in by EMS with C.C. of lower abdominal pain, N/V, and mild hypotension that corrected with a 500 ml bolus of IV saline. She appears to be stable, slightly pale, and tired-looking. She replies to questions of an Internal Medicine Resident who is doing a Review of Systems and Family History.
Labs are drawn with a second IV. "Hmm, how could a healthy woman become ill so quickly? I What's the worst thing that this could be?" She was, as the French say, a woman of a certain age: middle-aged but difficult to estimate her years, not yet very old. Was she fertile and still capable of an ectopic pregnancy? "What is the shortest way to ask? "Do you still have periods?" "Why, yes, I do." "When was the first day of your last period?" "Six weeks ago." At this point, the Resident caught the drift and inquired "Is there a possibility that you could be pregnant?" To which the patient demurely replied "Well, I am married, you know."
Next task was a catheter urine specimen and point-of-care testing for Hcg. In five minutes, the positive urine result was shown to the Resident: "She's pregnant. She needs an ultrasound NOW." The Attending Physician is shown the tell-tale test. Again, "She's pregnant. She needs an ultrasound NOW."
POCUS showed a lake of free blood in her abdominal gutters that was visibly increasing. Two units of Type O Negative blood were transfused immediately. Emergency surgery began within the hour of arrival. Three more units were given during the successful surgery. Six days later, the patient was seen for an unrelated minor complaint prior to return to her own country. She was forty-six years old.
Lessons learned:
- Trust your instincts; especially if you think that something could go wrong.
- Start with a "worst possible case differential diagnostic scheme. What is the worst that this could be? What could go wrong here? What needs to be done next?
- Do not slavishly follow a formal exam process. Be capable of Skip-Branch thinking; moving laterally or changing aspects of your internal algorithm as data presents.
- Be aggressive in diagnosing and treating the marginally unstable until the situation is clear. Marshal your resources early. Each clinical step prepares for the next possibility.
All Tips: 2013 2014 2015 2016 2017 2018 - Updated! (7/16/2018)
