A 46-year-old man presented to the ED after the sudden onset of chest pain 45 minutes earlier. He had been straining (installing a fan) when the pain began. He described the pain as a severe pressure that radiated to his left shoulder and arm. No radiation to the neck or back was noted. He denied shortness of breath, nausea, diaphoresis, syncope or palpitations. He had not previously experienced similar symptoms and felt well until the moment the pain began. Past medical history included poorly controlled hypertension for 15 years and a 35 pack-year smoking history.

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C orrect diagnosis is number 1: Ectopic pregnancy. The patient failed to return for her scheduled follow-up, but presented 4 days later with severe abdominal pain and vaginal bleeding. At this time she was restless and acutely distressed. Respiratory rate was 24 breaths/min, oxygen saturation 94% on room air, heart rate 80 beats/min, blood pressure 70 mm Hg by palpation and temperature 36°C. Her abdomen was rigid and diffusely tender, and a rectal exam was negative for blood. Her hemoglobin level was 86 g/L and a repeat quantitative beta-hCG was 262 mIU/ml. She was stabilized in the ED and transferred to the operating room, where laparotomy revealed a ruptured tubal gestation and 2 litres of intraperitoneal blood. Extensive adhesions related to pelvic inflammatory disease were also noted. A tuboplasty was performed and she recovered uneventfully.Ectopic pregnancy (EP) is the leading cause of first trimester death and accounts for 10% of pregnancy-related mortality. Early diagnosis saves lives and preserves fertility, but the diagnosis is often difficult, since 15% of patients report normal menstruation, 50% have no predisposing risk factors and only half have a palpable mass on pelvic examination. Diagnosis, therefore, often depends on obstetrical ultrasound and quantitative beta-hCG measurements.Transabdominal sonography is widely used but is unreliable if the beta-hCG is less than 6500 mIU/ml or the gestational age under 6 weeks. Early in pregnancy, transvaginal sonography (TVS) is superior -often being diagnostic without the need for quantitative betahCG levels. A recent meta-analysis reports that TVS is 84.4% sensitive and 98.9% specific for EP. 1 TVS findings should be interpreted in light of quantitative beta-hCG results. In patients who have symptoms compatible with EP, the combination of an empty uterus on TVS and a betahCG level greater than 1500 mIU/ml is said to be to 97% sensitive and 95% specific for ectopic pregnancy.2 However, low serum beta-hCG levels may be falsely reassuring. A normal TVS (empty uterus with no pelvic pathology) combined with a beta-hCG less than 1500 mIU/ml is compatible with early viable intrauterine pregnancy (IUP), nonviable IUP or ectopic pregnancy, 3 and 13% to 40% of patients in this group have an ectopic. 4 Unstable patients and those with significant abdominal tenderness should have immediate obstetrical consultation, but in stable patients with normal TVS and low beta-hCG, it is reasonable to perform serial beta-hCGs. The mean doubling time for patients with normal IUP is 1.9 +/− 0.5 days (when initial beta-hCG level is less than 10,000 mIU/ml). Over a 48-hour observation time, serum beta-hCG will rise more than 66% in most normal pregnancies and less than 66% in most ectopic pregnancies. Declining betahCG values suggest a nonviable pregnancy but do not differentiate IUP from EP. In the case of a blighted IUP, levels tend to decline rapidly, with a half-life of 1.4 days.5 A more gradual decline suggests ectopic pregnancy, as was true in the case above.Unfortunately, ru...

A 39-year-old Asian male presented to the ED complaining of weakness that began gradually after eating a large meal. His legs were affected more than his arms and, over 3 to 4 hours, the weakness progressed to the point that he could no longer bear weight. He also noted palpitations and tingling in both legs, but there was no headache, dizziness, diplopia, dysphagia, dysarthria or shortness of breath. On further questioning, he reported a tremor, heat intolerance, diaphoresis and palpitations, and a loss of 20 pounds over a 2-month period.