So hopefully no one of consequence reads this, and even if they do, hopefully they won't guess who I'm talking about (yikes, HIPAA!) But, anyway, yesterday I fell for one of the classic blunders. Now, my excuse is that I was trying to interview someone through MSN, which is definitely not recommended. Though one can only wonder if I would've figured it out if she were right in front of me. I also blame the fact that I did my internal medicine rotation at a VA, so that I never saw any female patients and never thought about it, and that my OBGYN rotation was such a living hell that I really didn't learn anything. Frighteningly, the only time that I had to manage a patient with pelvic inflammatory disease (I think she was positive for both gonorrhea and chlamydia) was during my pediatrics rotation, but that's another story.

So, anyway, a friend of mine asks me about this recurrent symptom she's been having. She's been having this feeling of bloating after eating dinner, pretty much for the last four weeks or so. I immediately ask her if she's having any pain on her right side when this happens, particularly below her ribs (i.e., right upper quadrant) and she says she hasn't been. Now, my differential is still: gallbladder/biliary tract dysfunction, GERD and/or PUD (since she eventually localized these sensations to between her epigastric region). It might have been a tip off when I asked her if she's tried antacids, that she's been trying to avoid using any sort of medication. I mean, lots of people have objections to taking pills unnecessarily, even if it's as innocuous as OTC antacids. Then it finally occurs to me to ask: well, maybe it's related to your menstrual cycle. Do you think?

And she says, well, yeah, maybe.

Hmmm, when's the last time you had a period?

About 13 weeks ago.

It takes me like several minutes to put two and two together.

Any attending would've slapped me on the head for not thinking about it in the first place.

So of course you never remember any of these rules until you forget them (and hopefully you don't forget them when it's really important for you to remember) but, let me reiterate one of the first things I learned in the ER: given a complaint of abdominal pain or discomfort in a woman of child-bearing age, pregnancy is at the top of the differential until proven otherwise.

So now I have to ask my buddy who is now an OBGYN intern: could it be cholestasis, reflux, or is it just one of those things that happen when your 13 weeks pregnant?

Man, I need to be more up on my stuff, though. The 4th year attrition of knowledge is apparently in full effect.