Asynchronous Interactive Module (AIM)

Abdominal Pain - Young Female

Objectives
By the end of this module, you should be comfortable:

Providing a list of the critical diagnoses to consider in a young female patient presenting
to the ED with abdominal pain
Discussing the differences in the initial assessment, workup, treatment and disposition
for these critical diagnoses

Preparatory Work
Before continuing, read the following:

http://www.cdemcurriculum.org/index.php/ssm/show_ssm/approach_to/abd_pain
Pearls and Pitfalls in the Emergency Department Evaluation of Abdominal Pain
Kamin, R. A., Nowicki, T. A., Courtney, D. S., & Powers, R. D. (2003). Pearls and pitfalls in the
emergency department evaluation of abdominal pain. Emergency Medicine Clinics of NA, 21(1),
6172, vi.

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Abdominal Pain - Young Female
Case Presentation:
A 22 year-old female presents with a chief complaint of RLQ pain. Her triage vitals signs are:
BP: 120/80, HR 95, T 98, R 15, O2 sat 100%.
The triage note says it began approximately 24 hours ago and is getting worse. She vomited
once this morning. You see them wheel her to the room and she appears uncomfortable but
not in any distress.
As you walk to the room, a list of the critical diagnoses you need to address for a patient of this
age, sex and chief complaint should pop into your head. List them here.
1

Appendicitis

Ruptured ectopic pregnancy

Ovarian torsion

PID

Tubo-ovarian abscess

Perforated viscus

SBO

What is the most important initial order, as its result will change your approach to this patient?

Pregnancy test
While you await for the results of this test, you go in the room to obtain your H&P...

Asynchronous Interactive Module (AIM)

Abdominal Pain - Young Female
Case Presentation:
She reports the pain began yesterday afternoon. It was gradual in onset and initially
intermittent but has become more constant. It is a sharp pain, radiating to her right flank
and worse with change in position. She has been nauseous and reports a lack of appetite.
She vomited once this morning, and denies any hematemesis. She feels warm but hasnt
taken her temperature. She denies vaginal bleeding, but admits to some mild vaginal
discharge without an odor. Her LMP ended 1 week ago, though it was light for her, lasting
only 2 days. She denies urinary frequency but has had mild dysuria.
Her past medical history includes gonorrhea and one previous spontaneous miscarriage.
She is sexually active with more than one male partner. She denies prior abdominal
surgeries.
Exam: RLQ and suprapubic tenderness to palpation with mild guarding and no rebound;
No CVA tenderness. Negative Murphys sign. Negative Rovsings and psoas signs.
Pelvic Exam reveals mild CMT and some tenderness to palpation and fullness of the right
adnexa. Blood-tinged cervical discharge noted.

Refining your differential

Based upon this H&P, what are your most likely diagnoses (reorder your initial differential from
most to least)?
1

Ectopic pregnancy

PID

Ovarian abscess

Appendicitis

Ovarian torsion

6
7

Asynchronous Interactive Module (AIM)

Abdominal Pain - Young Female
Read the following on CDEMCurriculum.org:
Appendicitis
Biliary Tract Disease
Ectopic Pregnancy
PID/TOA
Ovarian Torsion
In what ways would you expect this history and physical to be different to prompt you to have
the following as the most likely diagnosis in your differential:
Appendicitis?

Acute onset, Pain starts periumbilical and migrates toward mcburney point.
elevated WBC w/ left shift, (+) Rovsing, psoas, obturator sign.
Ectopic Pregnancy?

triad of abdominal pain, delayed menses, vaginal bleeding

Tenderness on pelvic exam, occ. palpable pelvic mass

Kidney Stone?

Colicky pain that starts in flank and radiates into groin area.
Hx of kidney stones, dehydration, crohns
Ovarian Torsion?

Sudden onset unilateral lower abd pain initially vague and poorly localized a/w n/v

May radiate to groin/flank. May be long hx if torsion occurs intermittently.

Cholelithiasis/Cholecystitis?

Colicky RUQ pain worse after eating large, fatty meals

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Abdominal Pain - Young Female
Workup
We really need that test result dont we?! What additional labs and imaging would you consider
AND WHY if the pregnancy test is...
Positive?

transvaginal Ultrasound --> determine if there is intrauterine pregnancy, look for ectopic

Abdominal US can also look for free fluid indicating rupture --> OR
Negative?

Abd CT --> can ID many other causes including appendicitis

Similar to a Choose Your Own Adventure Book, this case has 4 different endings...

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Abdominal Pain - Young Female
Scenario A:
Pregnancy Test positive. Her pain is increasing and repeat vital signs are:
BP: 90/50, HR 115, T 99, RR 20, O2 sat 100%.
You astutely ordered a bHCG which is 800. This patient needs an Ultrasound!

In this patient scenario, where is the best place to perform the ultrasound and what type(s) of
ultrasound should be performed?

Transvaginal US is best way to determine if pregnancy is intrauterine.

Since patient is hemodynamically unstable, should be taken to OR by obgyn

Ultrasound results: Complex mass in the RLQ. No identifiable intrauterine pregnancy.

Describe your stabilization treatment in the ED and the disposition for this patient.

Fluid and blood rescuscitation, pain management, obgyn consuklt. Rhogam admin.
If unstable --> OR, if stable --> methotrexate can be used

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Abdominal Pain - Young Female
Scenario B:
Pregnancy Test positive. Her pain is increasing and repeat vital signs are:
BP: 90/50, HR 115, T 99, RR 20, O2 sat 100%.
You astutely ordered a bHCG which is 800. This patient needs an Ultrasound!

Ultrasound results: No identifiable intrauterine pregnancy. No ovarian masses.

Describe your stabilization treatment in the ED and the disposition for this patient. Does this
change with a normal FAST? Why or why not?

Rapid assessment of vital signs, 2 large bore IVs, type and screen. bolus normal saline

FAST exam --> if abnormal take to OR, if normal can continue to monitor and evaluatre

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Abdominal Pain - Young Female
Scenario C:
Pregnancy Test positive. Her pain is unchanged and repeat vital signs are also unchanged:
BP: 120/80, HR 95, T 98, R 15, O2 sat 100%.
You astutely ordered a bHCG which is 800. This patient needs an Ultrasound.

Ultrasound results: No identifiable intrauterine pregnancy. No ovarian masses. FAST is normal.

The only thing different in this scenario is the patients clinical appearance. Do your treatment
and disposition change and if so, how?

Yes, patient is stable so may be managed expectedly rather than emergently.

Discuss the significance of the bHCG in this setting. How would your management change if it
was 2000?

IUP is usually visible via transvaginal US by 1500-2000 miu/mL

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Abdominal Pain - Young Female
Scenario D:
Pregnancy Test negative. Her pain is increasing and repeat vital signs are:
BP: 90/50, HR 115, T 101, R 20, O2 sat 100%.
WBC 15.0. H&H normal. Rest of labs normal. This patient also needs an ultrasound.

Ultrasound results: Complex right ovarian mass.

What is the diagnosis?

Tubo-ovarian abscess
Describe your stabilization treatment in the ED and the disposition for this patient.

vitals, 2 large bore IVs, normal saline bolus. Prep for OR

How does your diagnosis and management change if the ultrasound is normal?

No need to rush to OR, can monitor

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Abdominal Pain - Young Female

Finally, if you are unable to determine a diagnosis, what is the key part of any disposition plan?

Stabilize, determine if they can be discharged, taken to OR or admitted