Patients love imaging!
A girl in her mid-teens presented with acute suprapubic pain that woke her that morning. It was described as a cramping or burning. It was persistent although not as severe at the time of physician assessment. In fact, it had become rather mild. There was no radiation. She had never had it before. Her last period was three weeks prior. There was no history of fever, nausea/vomiting, or any stool or urine changes. There was no discharge. The sexual/STD history was negative. Her past medical history was negative for any chronic diseases or surgery. She was not a smoker or drinker and did not use any drugs. On examination, she appeared to be in no distress and was not in visible discomfort at all. Her vital signs were normal with the exception of a heart rate of 112 at triage. When assessed by the physician, her heart rate had normalized. Her examination was normal with the exception of some very mild suprapubic tenderness. A pelvic examination was not performed due to the negative sexual history. Testing initiated at triage included a normal CBC and chemistries. Her urine was completely negative. Her pregnancy test was negative as well. Although the timing was not completely perfect, it sounded like a ruptured ovarian cyst to the treating physician. Given that the presentation otherwise had no red flags and that the examination was fairly benign, the physician planned to discharge the patient with the probable diagnosis of ruptured ovarian cyst and reassurance, along with over-the-counter pain medication as needed.
When the physician offered this explanation and plan to the patient and her parents, the parents were a little bit concerned that her pain could be so dramatic initially. They were concerned that something more sinister was at play. So, in order to reassure the parents, a bedside ultrasound was performed. Here is the pelvic scan in the transverse plane.
Do you see any abnormalities on this video? If you’re not sure, go ahead and play it again. When you’re ready, watch the same video below with animations.
That was an ovarian cyst. It is a little bit involuted, which makes sense in the case of a rupture. You may have also noticed a thin rim of free fluid around the ovary and uterus. The free fluid prompted a scan of the RUQ.
Obvious free fluid in the RUQ. Did the POCUS result change the diagnosis and plan? No, not really. But it made the parents happier. There’s nothing like seeing an image that shows the diagnosis. Even better when you can show it to the patient’s parents 🙂
A blog post earlier this year from Lloyd Gordon presented a case of a hemorrhagic ovarian cyst. What is the difference between this case and that one? The clinical presentation, that’s it. Change the presentation and these scans could be entirely consistent with a hemorrhagic ovarian cyst in an unstable patient.
One last thing to add. We don’t specifically teach the diagnosis of ovarian cysts in any of the EDE courses. So if you are not sure of what you’re looking at, it is always prudent to get an elective ultrasound.