A 22-year-old woman presents to the emergency department with pain in her right lower quadrant (RLQ) that has been getting progressively worse over the past 18 hours.  The patient is very thin and is experiencing nausea along with the pain. She denies experiencing vomiting, diarrhea, vaginal discharge, fever, dysuria, missed menses, or other symptoms.

Physical examination is normal except for focal tenderness along the RLQ. Pelvic examination is deferred until further testing is conducted. The initial differential diagnosis includes appendicitis, ovarian cysts, and ectopic pregnancy. Laboratory testing rules out pregnancy, but her white blood cell count is elevated (14 x 109/L). A bedside ultrasound of the patient’s abdomen is performed (Figure).

What does the ultrasound show? What is the next best step in testing and treatment?

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