Author: Nicola Jakeman / Reviewer: Amanda King / Codes: CC1 / Published: 26/05/2021
Prerequisites:
This question is aimed at CT1 and above. It focuses on decision making.
Scenario:
A woman presented to the Emergency Medicine (ED) with diarrhoea and vomiting. She also had vaginal bleeding, fainting and severe abdominal pain. The patient told the doctor that she might have eaten some uncooked chicken the previous evening. She was known to be about 7 weeks pregnant. The patient was seen by a junior emergency physician and then reviewed by a junior gynaecologist. The gynaecologist diagnosed the patient as having gastroenteritis and discharged her.
The patient returned to the ED with increased pain at 2am the following night having collapsed at home. She was found to be hypotensive and tachycardic. The notes written by the gynaecologist from the previous day were reviewed and the likely diagnosis of gastroenteritis was noted. The patient was seen by a junior emergency physician who was also managing a couple of other patients. There was one other ED doctor on shift and 30 patients in the department.
The patient was given a large amount of fluid for what was presumed to be dehydration secondary to gastroenteritis, and some morphine. The patient was not reviewed in the ED by a senior emergency physician or gynaecologist. The patient was then discharged at 4 hours. At this point she remained tachycardic, although this had improved and her blood pressure was within the normal range.
Other than a B-HCG no other investigations were performed.
She returned a few hours later in extremis. Autopsy revealed a large haemoperitoneum from a ruptured tubal pregnancy.
