A 23-year-old woman presents to the emergency department with abdominal pain in her right lower quadrant and suprapubic region that began 12 hours ago. Her physical exam reveals tenderness in the right lower quadrant and suprapubic areas. Imaging and labs are ordered which ultimately reveal a ruptured corpus luteum cyst.

1. Case Presentation UT-Houston Emergency Medicine Rotation, August 2008 James Booth

2. 23-yr-old Woman CC: Abdominal Pain

3. RLQ / Suprapubic , 8/10, cramp-like pain Started 12 hrs ago and worsened over the course of 30 minutes. It has been constant since then. Pain is worsened with movement , including change in position. Took one vicodin with no relief . Pain feels similar to monthly cramps but more constant & worse. HPI

4. No fevers/chills. No N/V. No diarrhea. Tolerating PO, but decreased appetite since onset on pain. No vaginal discharge or bleeding LMP : June 23 rd (~ 2 months ago ) History of irregular periods . Patient has taken 2 home pregnancy tests over last 2 months. Both negative . HPI

5. No wt changes. No URI Sx. No SOB/CP. (+) Pressure-like, suprapubic pain with urination today. No blood in urine. No black or bloody stools. No rash. ROS

6. PMH No medical problems. No history of STDs. G2P1011 PSH C-section for NRFHTs Medications None Family History No significant history Social No smoking/EtOH/drugs Sexually active.

7. Physical Exam T 98.8, P 96, R 16, BP 86/66  114/69 , Sat 97% Gen: Noticeably uncomfortable HEENT: Moist mucous membranes, no pallor CHEST: CTA CV: Normal S1S2, No M/R/G, cap refill <2 secs ABD : Soft. Non-distended. (+) Bowel sounds. Tender in RLQ and suprapubic areas. Voluntary guarding. Weakly (+) Rosving sign. Weakly (+) Psoas sign. No pain with percussion. No CVAT. No masses palpated.

8. Physical Exam Pelvic: No cervical discharge. No blood. Cervix was unremarkable. Small uterus. No adnexal tenderness or masses. Exquisite cervical motion tenderness . Rectal: Nontender Negative hemoccult.

10. Differential Diagnosis Appendicitis PID / Cervicitis Ovarian Cyst / Torsion Ectopic Pregnancy

11. The Hunt Begins… UPT Negative UA 6-10 WBCs CBC WBC 17.3 Hg 11.4

12. Color flow Doppler Ultrasound

13. Triple Contrast CT

15. Radiology attending was highly suspicious of ectopic; Requested a HCG  <1

16. Treatment & Dispo Pain control IVF / NPO Serial Abd Exams Consult Gen Surg

18. What was it??? Diagnostic Laparoscopy: Ruptured Corpus Luteum Cyst

19. Approach to Abdominal Pain in a Woman of Childbearing Age

20. Abdominal pain makes up ~ 7% of all reasons for ED visits.

22. The differential is broad . A good H&P is crucial.

23. Table 36-2 Emergency Medicine: A Comprehensive Study Guide, 6th ed. Most Common Causes of Acute Abdominal Pain Final Diagnosis Proportion Nonspecific abdominal pain (NSAP) 34% Appendicitis 28% Biliary tract disease 10% Acute gynecologic disease 4% Salpingitis 68% Ovarian cyst 21% Ectopic 6% Incomplete abortion 5% Small bowel obstruction 4% (2% if <50yo) Pancreatitis 3% Renal colic 3% Perforated peptic ulcer 3% Cancer 2% Diverticular disease 2% Other (<1% each) 6%

24. Patient Management Recommendations: Evaluating Abdominal Pain (ACEP Clinical Policies) Guidelines. 1. Do not restrict the differential diagnosis solely by the location of the pain. 2. Do not use the presence or absence of a fever to distinguish surgical from medical etiologies of abdominal pain. Options. 1. Use serial evaluations over several hours to improve the diagnostic accuracy in patients with unclear causes of abdominal pain. 2. Collect a complete data set before reaching a differential diagnosis; consider a systemic data collection tool, such as a formatted chart. 3. Perform a stool for occult blood test in patients with abdominal pain. 4. Perform a pelvic examination in female patients with abdominal pain.

25. pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test pregnancy test

26. UPT & UA CBC BMP, lipase, HCG Labs

27. Imaging Modalities Appendicitis Contrast CT RLQ Ultrasound Biliary track RUQ Ultrasound disease HIDA / CT Ovarian Color flow Torsion Doppler Ultrasound Ectopic preg Trans-vaginal U/S Kidney stone Non-contrast CT Ann Emerg Med. October 2000;36:406- 415

28. http://flickr.com/photos/24973901@N04/2762458387/sizes/o/

29. A 23 year-old woman presents to the ED in moderate pain in her left lower quadrant . She states that the pain began suddenly and is associated with nausea and vomiting. She had a bout of diarrhea yesterday. This is the second time in the month that she experienced pain in this location, however, never with this severity. Her BP is 120/75 mmHg, HR is 101 beats per minute, temperature is 99.5F, and RR is 18 breaths per minute. She has a tender left lower quadrant on abdominal exam and a tender adnexa on pelvic exam. Which of the following is the most appropriate diagnostic test for the patient? a. CT scan b. MRI c. X-ray d. Doppler US e. Laparoscopy

30. A 23-year-old woman presents to the ED complaining of lower abdominal pain and vaginal spotting for 2 days . Her BP is 115/75 mm Hg, HR is 75 beats per minute, temperature is 98.9F, and RR is 16 breaths per minute. Which of the following tests should be obtained next? a. Abdominal CT scan b. b-Human chorionic gonadotropin (b-hCG) c. Transvaginal ultrasound d. Abdominal radiograph e. Chlamydia antigen test

31. A 19-year-old woman presents to the ED complaining of lower abdominal pain over the past 14 hours that is associated with a loss of appetite and mild nausea. She states she is sexually active and is on oral contraceptives. Her last menstrual period was 3 weeks ago . Her temperature is 100.2F . Her abdomen is tender to palpation in the RLQ of the abdomen and palpation over other areas of the abdomen also results in RLQ pain . Bowel sounds are absent. Pelvic exam reveals scant white discharge from the cervical os. There is no cervical motion tenderness and the adnexae and ovaries appear normal. Which of the following is the most likely diagnosis? a. Ectopic pregnancy b. Appendicitis c. Ovarian cyst d. Tubo-ovarian abscess e. Renal calculus

32. A 27-year-old woman presents to the ED with sudden onset severe RLQ pain and pelvic pain that began 4 hours ago. She is nauseated and vomited twice in the ED. She states that her last menstrual period was 3-4 weeks ago. Her BP is 123/78 mm Hg, HR is 94 beats per minutes, temperature is 99.1F, and her RR is 17 breaths per minute. Physical exam is remarkable for right adnexal fullness and tenderness without peritoneal signs. Transvaginal ultrasound reveals a simple 8-cm cyst on the right ovary, without free fluid. Laboratory tests are all within normal limits and her b-hCG is negative . What is the most likely diagnosis? a. Appendicitis b. Ectopic pregnancy c. Tubo-ovarian abscess d. Mittelschmerz e. Ovarian torsion

33. A 23-year-old woman presents to the ED with RLQ pain for the last 1-2 days . The pain is associated with nausea, vomiting, diarrhea, anorexia, and fever of 100.9F . She also reports dysuria . The patient returned 1 month ago from a trip to Mexico. She is sexually active with one partner but does not use contraception. She denies vaginal bleeding or discharge. Her last menstrual period was approximately 1 month ago . She has a history of pyelonephritis . Based on the principles of Emergency Medicine, what are the three priority considerations in the diagnosis of this patient? a. Perihepatitis, gastroenteritis, cystitis b. Ectopic pregnancy, appendicitis, pyelonephritis c. PID, gastroenteritis, cystitis d. Ectopic pregnancy, pelvic inflammatory disease, menstrual cramps e. Gastroenteritis, amebic dysentery, cramps

34. References John Ma, David Cline. Emergency Medicine Manual . American College of Emergency Physicians. Clinical policy: critical issues for the initial evaluation and management of patients presenting with a chief complaint of nontraumatic acute abdominal pain. Ann Emerg Med. October 2000;36:406- 415 Rosen’s Emergency Medicine: Concepts and Clinical Practice , 6th Editon, Chapter 22 Adam Rosh, Stephen Menlove. Pretest Emergency Medicine . First Edition. Eugene Toy, Barry Simon . Case Files: Emergency Medicine