The Case


Abdominal pain


27yF with h/o anxiety p/w abdominal pain x1d. Pain started yesterday evening, intermittent, a/w nausea and diaphoresis. Began as generalized pain but when supine, radiates to chest a/w mild SOB, otherwise localizes to the right abdomen with radiation to the pelvis.

Denies fever, chills, diarrhea, anorexia, blood in stool, recent travel, sick contacts. Sexually active with one male partner, denies STIs, uses OCPs, LMP 3 weeks ago. Denies vaginal bleeding or discharge.

The remainder of the patient’s labs other than those given are pending. On assisting the patient to the OBGYN room, she becomes markedly diaphoretic, lightheaded, tachycardic to 125, and hypotensive to SBP in the 60s. Repeat EKG shows sinus tach, portable CXR is unremarkable, and a RUSH bedside ultrasound exam notable for free fluid in the pelvis.


PMH: anxiety, HPV
PSH: none
Social: denies tobacco, drug use. Rare social etoh
Meds: OCPS
Allergies: NKDA

Physical Exam

BP 96/52 HR 99 Resp 18 Sat 100% Temp 96.0
General: well-dressed, appears stated age, lying semi-recumbent in stretcher, no acute distress
CV: RRR, no m/r/g
Pulm: CTA throughout, breathing comfortably on room air, tachypneic when supine
Abdomen: soft, nondistended, mild TTP in RLQ, no rebound or guarding
Neuro: Awake, alert, orient, normal strength, sensation, coordination
Ext: normal active ROM, no deformities or edema
Skin: no diaphoresis, rashes, or lesions. Warm and dry.


  1. What next steps would take in the management of this patient?

  2. What is your differential for this patient?