Case Evaluation: Abdominal Pain in a Young Female
Case study: I have pain in my belly
A 25-year-old female presents to the emergency room (ER) with complaints of severe abdominal pain for 2 weeks . The pain is sharp and crampy It hurts if I run, sit down hard, or if I have sex
Patient denies past medical history
Is on Birth control
Has no known allergies
Subjective data: Nausea and vomiting, Last menstrual period 5 days ago, New sexual partner about 2 months ago, No condoms, he hates them No pain, blood or difficulty with urination
Physical exam- Objective data: B/P 138/90; temperature 99F; (RR) 20; (HR) 110, regular; oxygen saturation (PO2) 96%; pain 5/10
acute distress and severe pain
HEENT: Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.
Lungs: CTA AP&L
Cardio: S1S2 without rub or gallop
Abdominal: INSPECTION: no masses or thrills noted; no discoloration and skin is warm to; no tattoos or piercings; abdomen is nondistended and round
AUSCULTATION: bowel sounds (BS) are normal in all four quadrants, no bruits noted
PALPATION: on palpation, abdomen is tender to touch in four quadrants; tenderness noted on light palpation, deep palpation reveals no masses, spleen and liver unremarkable
PERCUSSION: tympany heard in all quadrants, no dullness noted in abdominal area
Genitalurinary: EXTERNAL: mature hair distribution; no external lesions on labia
INTROITUS: slight green-gray discharge, no lesions
VAGINAL: normal rugae; moderate amount of green discharge on vaginal walls
CERVIX: nulliparous os with small amount of purulent discharge from os with positive cervical motion tenderness (CMT)
UTERUS: ante-flexed, normal size, shape, and position
ADNEXA: bilateral tenderness with fullness; both ovaries without masses
RECTAL: deferred
VAGINAL DISCHARGE: green in color
ext: no cyanosis, clubbing or edema
integument: intact without lesions masses or rashes
Neuro: No obvious deficits and CN grossly intact II-XII
Once you received your case number, answer the following questions:
What other subjective data would you obtain?
What other objective findings would you look for?
What diagnostic exams do you want to order?
Name 3 differential diagnoses based on this patient presenting symptoms?
Give rationales for your each differential diagnosis.
Case Evaluation: Abdominal Pain in a Young Female
Additional Assessment and Diagnosis
Additional Subjective Data:
- Menstrual History: Menstrual regularity, duration, and flow pattern.
- Sexual History: Number of sexual partners, contraceptive use, history of sexually transmitted infections (STIs).
- Gastrointestinal Symptoms: Changes in bowel habits, presence of bloating, gas, or diarrhea.
- Pain Characteristics: Onset, severity, aggravating or alleviating factors, radiation of pain.
Additional Objective Findings:
- Pelvic Exam: Assess for cervical motion tenderness, uterine position, adnexal tenderness or masses.
- Laboratory Tests: Complete blood count (CBC), urinalysis, pregnancy test, STI screening.
- Imaging Studies: Pelvic ultrasound to evaluate pelvic organs, especially the ovaries.
- Diagnostic Procedures: Endometrial biopsy if indicated based on findings.
Differential Diagnoses:
1. Pelvic Inflammatory Disease (PID):
- Rationale: Green discharge, cervical motion tenderness, recent new sexual partner without condom use are consistent with PID. Can lead to chronic abdominal pain if left untreated.
2. Ovarian Cyst:
- Rationale: Bilateral ovarian tenderness and fullness suggest possible ovarian pathology. Ovarian cysts can cause sharp abdominal pain and discomfort during physical activities.
3. Endometriosis:
- Rationale: Severe menstrual cramps, pain during intercourse, and green vaginal discharge may indicate endometriosis. It can lead to chronic pelvic pain and discomfort.
Diagnostic Exams:
1. Pelvic Ultrasound: To assess the pelvic organs, including the uterus, ovaries, and fallopian tubes.
2. STI Screening: To rule out or confirm the presence of sexually transmitted infections.
3. Cervical Cultures: To identify any bacterial or fungal infections that may be causing the symptoms.
Treatment Plan:
- Empiric antibiotic therapy for suspected PID.
- Pain management for symptom relief.
- Follow-up pelvic exams and imaging studies for further evaluation and monitoring.
By conducting a comprehensive assessment, ordering appropriate diagnostic exams, and considering differential diagnoses, healthcare providers can formulate an accurate diagnosis and tailored treatment plan for young female patients presenting with abdominal pain and gynecological symptoms.