Case 2: Abdominal pain

Opening scenario

Anna Bush, a 23-year-old female; , comes to the emergency department because of abdominal pain.

Vital signs

• Temperature: 101.3°F (38.5°C)
• Blood pressure: 115/65 mm Hg
• Heart rate: 85/min
• Respirations: 22/min

Examinee tasks

• Take a focused history.
• Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

Patient instructions

• Hold the part of your abdomen right over your right groin and act as if you are in severe pain when the examinee asks you to move.
• Point at your abdomen right over your right groin when asked about the location of your pain.
• If the examinee presses on the right lower part of your abdomen, pretend that it hurts and flex your abdominal muscles.
• If the examinee presses on the right lower part of your abdomen, pretend that it hurts upon releasing the pressure.
• If the examinee presses on the left lower part of your abdomen, say that the right lower portion of it hurts.
• You are not aware of the meanings of medical terms (e.g., ultrasound) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: Ask “Am I pregnant?”

Hovering over or clicking on the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form or the abbreviation list will not interrupt your progress.

History of present illness

• Chief complaint
• My stomach has been hurting since this morning.
• Location
• On the right side, right above the hip bone.
• Intensity (on a scale from 0–10)
• At least a 9.
• Quality
• It is a really sharp pain.
• Onset
• I had some dull belly pain last night, but it was not as bad as this and also not in just one spot like it is now. The pain I am having right now started this morning.
• Precipitating events
• None.
• Progression/constant/intermittent
• The pain is there all the time, and I feel like it has been getting worse.
• Previous episodes
• None.
• Radiation
• No.
• Alleviating factors
• The pain gets a little bit better if I do not move or if I lie down.
• Aggravating factors
• The pain gets a lot worse if I get up and walk around.
• Associated symptoms
• I feel really nauseous but I have not vomited.

Review of systems specific to acute abdominal pain

• Recent travel
• No.
• Fever/chills
• I feel like I might have been running a fever since this morning. Did the nurse not take my temperature earlier?
• Rash/skin changes
• No.
• Pain in joints
• No.
• Urinary problems
• 2 weeks ago, I had a few days where it burned a little bit when I had to pee, but it went away by itself.
• Bowel problems
• I do not have diarrhea or constipation, just stomach pain.
• Appetite
• I have not eaten anything since yesterday. I really do not have much of an appetite.
• Weight changes
• None.
• Recent infections
• Hmm, not that I remember.

Past medical history, family history, and social history

• Past medical history
• I had really bad acne when I was younger but it has gotten better over the last year. And then I had chlamydia 2 years ago, but they gave me some antibiotics and it went away, too.
• Allergies
• None.
• Medications
• Oral contraceptive pill.
• Hospitalizations
• Never.
• Ill contacts
• No.
• Past surgical history
• None.
• Family history
• They are all healthy. Well, my mom says she has irritable bowel syndrome but I think that it is just stress.
• Work
• I am a college student.
• Home
• I live in a dorm.
• Alcohol
• No.
• Recreational drugs
• Never.
• Tobacco
• No.
• Diet
• I think I usually eat a balanced diet, lots of vegetables and some chicken or meat every couple of days.

Sexual history, OB/Gyn

• Sexually active
• Yes.
• With whom
• My boyfriend.
  • Pain during sex
  • Yes, it has actually been hurting over the past week.
• Number of partners over the past year
• Two. My current boyfriend and my ex-boyfriend.
• Protection
• I use oral contraceptives, if that is what you mean?
• Last menstrual period
• One week ago.
• Menarche
• When I was 13.
• Duration of period
• 4–5 days.
• Period regular
• Every 28 days, because I take birth control.
• How many tampons per day
• Two.
• Vaginal discharge
• None right now, but I had a little about 2 weeks ago that went away by itself.
• Vaginal itching
• No.
• Vaginal dryness
• No.
• Pregnancies
• No, I have never been pregnant, and I really do not want to have children yet.
• Last Pap smear
• Last spring, and everything was fine then.

A thorough sexual and gynecological history should be taken in female patients with lower abdominal pain, especially those with a history of dysuria!

• Washed hands
• Used respectful draping
• Cardiovascular examination
  • Auscultation of the heart
• Chest examination
  • Auscultation of the lungs
• Abdominal examination
  • Inspection of the abdomen
  • Auscultation of the abdomen
  • Percussion of the abdomen
  • Palpation of the abdomen
    • Tenderness and guarding in the right lower quadrant
  • McBurney sign
    • Positive
  • Blumberg sign
    • Positive
  • Psoas sign
    • Negative
  • Rovsing sign
    • Positive

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the patient).
• Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
• Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
• Examinee discussed initial diagnostic impressions with the patient.
• Examinee explained the management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated the patient's agreement with the next diagnostic steps.
• Examinee asked about concerns or questions.

Counseling and challenge

• Examinee offered counseling on safer sex practices.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: “Ms. Bush, I understand that you are concerned about a possible pregnancy. Based on what you have told me today and because you take the birth control pill, it is unlikely that you are pregnant. Nonetheless, it is not possible for me to say with certainty whether or not you are pregnant without performing a pregnancy test. To be sure, I would like to order a pregnancy test for you, if you're okay with that. No matter what the results of that test might be, I can assure you that I will be there with you every step of the way.”

Patient note

Differential diagnoses

1. Acute appendicitis: In acute appendicitis, the visceral peritoneum is affected first, causing diffuse abdominal or periumbilical/epigastric pain. After 4–24 hours, irritation of the parietal peritoneum by the distended and inflamed appendix occurs, which leads to localized pain in the right lower quadrant with tenderness and guarding. This sequence of events is very typical for acute appendicitis. Physical exam findings such as a positive McBurney, Blumberg, and Rovsing sign are also highly suggestive of acute appendicitis. The condition is typically associated with fever, nausea, and anorexia, as seen in this patient. Appendicitis can occur at any age but is most common in children and young adults.
2. Pelvic inflammatory disease (PID): Lower abdominal pain, fever, nausea, dysuria, dyspareunia, and abnormal vaginal discharge are typical clinical features in PID. While this patient's age and history of 2 sexual partners with whom she does not use barrier protection put her at increased risk for PID, the pain would usually be bilateral rather than localized to the right lower quadrant, and PID would not typically present with positive appendicitis signs (McBurney sign, Blumberg sign, Rovsing sign).
3. Ovarian torsion: Sudden onset, severe abdominal pain localized to the left or right lower quadrant in a woman of reproductive age is typical for ovarian torsion. The condition is often associated with nausea and can also present with a low-grade fever. However, this patient's pain was preceded by diffuse abdominal pain and the patient does not have any obvious risk factors for ovarian torsion (e.g., ovarian cyst, tumor, pregnancy).

Diagnostic studies

• Pelvic examination: essential part of work-up in this patient to evaluate for PID and ovarian torsion
• Cervical and urethral swab: PID is most commonly caused by Chlamydia trachomatis and Neisseria gonorrhoeae.
• Ultrasound of the abdomen and pelvis: can be used to assess for acute appendicitis, ovarian torsion, and ruptured ovarian cyst
• CBC with differential: Acute appendicitis typically leads to mild leukocytosis with left shift.
• Erythrocyte sedimentation rate: Pelvic inflammatory disease and acute appendicitis would present with an elevated ESR.
• Urine pregnancy test: to rule out (ectopic) pregnancy as a differential diagnosis as well as prior to ordering a CT of the abdomen
• U/A, urine culture: should be performed in every female patient with lower abdominal pain to rule out a urinary tract infection

Any woman of child-bearing age presenting with abdominal pain must have her beta-hCG levels checked to rule out pregnancy.

Other differential diagnoses to consider

• Ruptured ovarian cyst
• Ectopic pregnancy
• Pseudoappendicitis
• See differential diagnosis of lower abdominal pain in women of reproductive age and differential diagnoses of acute abdomen.