Ob/Gyn Case Challenge: A 33-Year-Old Woman Trying to Conceive Has Dyspnea, Pain

Ziad R. Hubayter, MD, MPH


May 19, 2022

Physical Examination and Workup

Upon physical examination, the patient is awake, alert, and oriented. She appears to be in moderate distress. Her pulse is 108 beats/min, and her blood pressure is 110/60 mm Hg. She has rapid, shallow breathing, with a respiratory rate of 26 breaths/min. The pulse oximetry reading is 95% while she is breathing room air, but it rises to 98% on 2 L/min oxygen supplementation.

The patient weighs 200 lbs (90.7 kg). Head and neck examination findings are unremarkable, without jugular venous distention. Her pulmonary examination reveals egophony, bilaterally decreased breath sounds, and a loss of tactile fremitus. The heart is regular, tachycardic, and without murmurs. The abdomen is distended, but normal bowel sounds are noted. No palpable mass or organomegaly is noted, but she exhibits moderate tenderness to palpation throughout the abdomen, with a positive fluid wave. A pelvic speculum examination reveals no vaginal bleeding or discharge. The bimanual examination is deferred.

Serum blood testing performed in the emergency department reveals a white blood cell count of 12.2 × 109/L (reference range, 4.5 to 11.0 × 109/L), hemoglobin level of 16.2 g/dL (reference range, 11.6-15 g/dL), hematocrit of 48.7% (reference range, 35.5% to 44.9%), sodium level of 130 mEq (reference range, 135-145 mEq), potassium level of 5.2 mEq/L (reference range, 3.5-5 mEq/L), blood urea nitrogen level of 10 mg/dL (reference range, 6-24 mg/dL), and creatinine concentration of 1 mg/dL (reference range, 0.59 to 1.04 mg/dL). Liver function tests and the remaining chemistry profile are normal.

An abdomen-shielded chest radiograph is obtained that reveals bilateral pleural effusions (not shown). Transvaginal ultrasonography is also obtained (Figures 1 and 2).

Figure 1.

Figure 2.


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