AIM Abd Pain Female(1)

7/23/2019 AIM Abd Pain Female(1)

1/10

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 presentingto the ED with abdominal pain

Discussing the differences in the initial assessment, workup, treatment and dispositionfor 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.

Asynchronous Interactive Module (AIM)Abdominal Pain - Young Female
http://www.sassit.co.za/Journals/Surgical%20emergencies/ABDOMINAL%20PAIN.pdfhttp://www.sassit.co.za/Journals/Surgical%20emergencies/ABDOMINAL%20PAIN.pdfhttp://www.cdemcurriculum.org/index.php/ssm/show_ssm/approach_to/abd_painhttp://www.cdemcurriculum.org/index.php/ssm/show_ssm/approach_to/abd_pain


2/10

As you walk to the room, a list of the critical diagnoses you need to address for a patient of thisage, sex and chief complaint should pop into your head. List them here.

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

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

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 vomitedonce this morning. You see them wheel her to the room and she appears uncomfortable butnot in any distress.


Pregnancy test

Appendicitis

Ruptured ectopic pregnancy

Ovarian torsion

PID

Tubo-ovarian abscess

Perforated viscus

SBO


3/10

Refining your differential

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

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Case Presentation:

She reports the pain began yesterday afternoon. It was gradual in onset and initiallyintermittent but has become more constant. It is a sharp pain, radiating to her right flankand 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 hasnttaken her temperature. She denies vaginal bleeding, but admits to some mild vaginaldischarge without an odor. Her LMP ended 1 week ago, though it was light for her, lastingonly 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 abdominalsurgeries.

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 rightadnexa. Blood-tinged cervical discharge noted.


Ectopic pregnancy

PID

Ovarian abscess

Appendicitis

Ovarian torsion


4/10

Read the following on CDEMCurriculum.org:

Appendicitis

Biliary Tract DiseaseEctopic PregnancyPID/TOAOvarian Torsion

In what ways would you expect this history and physical to be different to prompt you to havethe following as the most likely diagnosis in your differential:

Appendicitis?

Ectopic Pregnancy?

Kidney Stone?

Ovarian Torsion?

Cholelithiasis/Cholecystitis?


Acute onset, Pain starts periumbilical and migrates toward mcburney point.

elevated WBC w/ left shift, (+) Rovsing, psoas, obturator sign.

triad of abdominal pain, delayed menses, vaginal bleeding

Tenderness on pelvic exam, occ. palpable pelvic mass

Colicky pain that starts in flank and radiates into groin area.

Hx of kidney stones, dehydration, crohns

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.

Colicky RUQ pain worse after eating large, fatty meals
http://www.cdemcurriculum.org/index.php/ssm/show_ssm/gu/torsionhttp://www.cdemcurriculum.org/index.php/ssm/show_ssm/gu/torsionhttp://www.cdemcurriculum.org/index.php/ssm/show_ssm/gu/toahttp://www.cdemcurriculum.org/index.php/ssm/show_ssm/gu/toahttp://www.cdemcurriculum.org/index.php/ssm/show_ssm/gu/ectopichttp://www.cdemcurriculum.org/index.php/ssm/show_ssm/gu/ectopichttp://www.cdemcurriculum.org/index.php/ssm/show_ssm/gi/biliary.phphttp://www.cdemcurriculum.org/index.php/ssm/show_ssm/gi/biliary.phphttp://www.cdemcurriculum.org/index.php/ssm/show_ssm/gi/appy.phphttp://www.cdemcurriculum.org/index.php/ssm/show_ssm/gi/appy.php


5/10

Workup

We really need that test result dont we?! What additional labs and imaging would you considerAND WHY if the pregnancy test is...

Positive?

Negative?

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


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

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

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


6/10

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

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

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

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!


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

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

Fluid and blood rescuscitation, pain management, obgyn consuklt. Rhogam admin.

If unstable --> OR, if stable --> methotrexate can be used


7/10

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

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

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!


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


8/10

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 treatmentand disposition change and if so, how?

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

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.


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

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


9/10

Ultrasound results: Complex right ovarian mass.

What is the diagnosis?

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

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

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.


Tubo-ovarian abscess

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

No need to rush to OR, can monitor


10/10

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

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AIM Abd Pain Female(1)