Following an uncomplicated total abdominal hysterectomy for symptomatic leiomyomas, a 42-y… — USMLE Step 2 CK

Following an uncomplicated total abdominal hysterectomy for symptomatic leiomyomas, a $42$ -year-old female presents to the acute care clinic on postoperative day $6$ for evaluation of new-onset abdominal pain. For the past $48$ hours, she has experienced steadily worsening left lower quadrant pain that radiates to the left groin. The pain makes it difficult for her to lift her left leg when walking. She reports normal flatus, bowel movements, and urination. She has not had chills or vomiting. Vital signs are temperature $37.1^\circ\text{C}$ ( $98.8^\circ\text{F}$ ), blood pressure $118/76\text{ mm Hg}$ , pulse $92/\text{min}$ , and respirations $14/\text{min}$ . The surgical incision is clean, dry, and intact. Abdominal examination reveals a soft abdomen with deep tenderness in the left lower quadrant, lacking rebound tenderness or rigidity. When the examiner places a hand on the patient's left distal thigh and asks her to flex her hip against resistance while supine, the patient winces in severe pain. Laboratory evaluation reveals a leukocyte count of $8,500/\text{mm}^3$ and a hemoglobin concentration of $9.2\text{ g/dL}$ (down from $12.1\text{ g/dL}$ on postoperative day $1$ ). Which of the following is the most likely explanation for this patient's presentation?

Retroperitoneal hematomaCevap
B
Femoral nerve neuropathy
C
Pelvic abscess
D
Left ureteral transection
E
Ovarian vein thrombosis

Cevap

The most likely explanation is a retroperitoneal hematoma, indicated by the positive psoas sign and acute drop in hemoglobin.

The patient's clinical picture of deep lower quadrant pain radiating to the groin, a positive psoas sign (pain on resisted hip flexion), and a significant drop in hemoglobin without signs of external bleeding strongly suggests a retroperitoneal hematoma. During a total abdominal hysterectomy, the uterine arteries and other pelvic vessels are ligated near the pelvic sidewall. If a ligature slips or if there is unrecognized venous oozing, blood can accumulate in the retroperitoneal space. This blood easily tracks upward along the psoas major muscle, causing intense chemical irritation. This irritation is exacerbated when the muscle contracts (as seen with resisted hip flexion). The lack of fever and a normal leukocyte count make an infectious process highly unlikely, while the large drop in hemoglobin differentiates this from an isolated nerve injury.

Adım Adım Çözüm

Analyze the physical examination findings.

The patient experiences severe pain upon resisted left hip flexion, which is a positive psoas sign.

This indicates an inflammatory or space-occupying process directly irritating the psoas major muscle.

Evaluate the laboratory data in the context of the physical exam.

The patient has a

2.9\text{ g/dL}

drop in hemoglobin without signs of external bleeding, alongside a normal leukocyte count and lack of fever.

The hemoglobin drop confirms an acute internal hemorrhage, while the normal temperature and white count rule out an infectious abscess.

Synthesize the findings with the surgical history.

Bleeding from ligated pelvic vessels after a hysterectomy can track retroperitoneally, pooling along the psoas muscle, leading to a retroperitoneal hematoma.

This single diagnosis perfectly unifies the positive psoas sign, the pelvic surgery history, and the acute but concealed blood loss.

Anahtar Kavram

Retroperitoneal hematoma following pelvic surgery often presents with deep abdominal/groin pain, a positive psoas sign due to blood tracking along the muscle, and a significant drop in hemoglobin without overt signs of peritonitis or infection.

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