Case 3: Abdominal pain

Opening scenario

Stephanie Hernandez, a 34-year-old female; , comes to the doctor's office because of abdominal pain.

Vital signs

• Temperature: 99°F (37°C)
• Blood pressure: 118/76 mm Hg
• Heart rate: 68/min
• Respirations: 16/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

• When the examinee asks you where the pain is located, point at the right lower part of your abdomen.
• When the examinee presses on the right lower part of your abdomen, say that 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: After the examinee explains to you what she/he thinks your diagnosis might be, ask “Does this mean I am going to need surgery?”

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
• I have pain in my stomach.
• Location
• On the right side.
• Intensity (on a scale from 0–10)
• It has been a 1–2 for the past few weeks, but I'd describe it as a 5 starting this morning.
• Quality
• It was a dull pain, but I was working out this morning and all of a sudden felt a sharp pain there.
• Onset
• The dull pain has been there for a couple of weeks. The sharp pain since this morning, like I said.
• Precipitating events
• Nothing special besides the aerobics this morning.
• Progression/constant/intermittent
• The dull pain is always there, and now the sharp pain, too.
• Previous episodes
• Never.
• Radiation
• No.
• Alleviating factors
• I have been using a heating pad on it at night, I think it helps a little bit.
• Aggravating factors
• Nothing really except the aerobics this morning.
• Associated symptoms
• I have been feeling a little bloated too. I feel like I am heavier than I used to be.
  • Weight gain
  • Hmm, I am not sure – I don't have a scale. But my pant size has gone up in the last month as well.

Review of systems specific to abdominal pain and weight gain

• Trauma
• No.
• Recent travel
• I just came back from Paris a month ago.
• Nausea/vomiting
• I have been feeling a little bit sick to my stomach the past weeks, but I have not thrown up.
• Fever/chills
• No.
• Night sweats
• No.
• Fatigue
• I had a bad case of jet lag when I came back from Paris. It is slowly getting better.
• Shortness of breath
• No.
• Urinary problems
• Now that you mention it, I do feel like I have had to pee more than usual lately.
• Bowel problems
• No.
• Appetite
• Not very good because I have been feeling sick, like I told you.
• Recent infections
• No.

Past medical history, family history, and social history

• Past medical history
• I get migraines.
• Allergies
• No.
• Medications
• I take a multivitamin and ibuprofen when I have a headache.
• Hospitalizations
• I was hospitalized with an infection in my hip joint as a child.
• Past surgical history
• None.
• Family history
• My mother was diagnosed with breast cancer when she was 51, my sister was diagnosed with breast cancer when she was only 39 years old. My grandmother had ovarian cancer. My father is healthy.
• Work
• I am a European tour guide.
• Home
• My husband is an airline pilot, so we both travel a lot, which can be stressful. We both look forward to our time together at home.
• Alcohol
• I like to drink a glass of wine with dinner.
• Recreational drugs
• No, never.
• Tobacco
• No.

Sexual history, OB/Gyn

• Sexually active
• Yes, with my husband.
• Number of partners over the past year
• Just my husband.
• Protection
• We do not use protection. We are just careful around the time that I am ovulating.
• Last menstrual period
• I think it was 2 weeks ago; . I am not even sure it was a period though, because it was late and very light – just some spotting.
• Menarche
• I was 10 years old.
• Duration of period
• 4 days.
• Period regular
• Usually, yes. Just this time it has been different.
• How many tampons per day
• Maybe 3.
• Vaginal discharge
• Normal.
• Vaginal itching
• No.
• Pregnancies
• None. We have both been very busy with our careers and do not want to have children right now.
• Last Pap smear
• 10 months ago. It was normal.

• Washed hands
• Used respectful draping
• Head, eyes, ears, nose, and throat examination
  • Inspection of the conjunctivae
• Cardiovascular examination
  • Auscultation of the heart
• Chest examination
  • Percussion of the lung fields
  • Auscultation of the lungs
• Abdominal examination
  • Inspection of the abdomen
  • Auscultation of the abdomen
  • Percussion of the abdomen
  • Palpation of the abdomen
    • Tenderness in the right lower quadrant

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 did not repeat painful maneuvers during physical examination.
• 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 contraception options.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: “Ms. Hernandez, I understand your concern that you will have to undergo surgery. Right now, it is not possible for me to say what exactly is causing your pain. In order to do that, I will have to run some tests and do a pelvic examination, as well as do some imaging of your abdomen. Then you and I can discuss the results and the possible treatment options together. Does that sound okay? I promise you I will be with you every step of the way.”

Patient note

Differential diagnoses

1. Ovarian cancer: Although they are unspecific symptoms, dull lower abdominal pain, increased urinary frequency, decreased appetite, and changes in the menstrual cycle (spotting) can all be signs of ovarian cancer and warrant further evaluation. Additionally, an increase in abdominal girth is often the first sign of ovarian cancer and early menarche and nulliparity are risk factors. Although ovarian cancer is rare in young women, this patient's family history is concerning for a BRCA mutation which would significantly increase her risk for both ovarian and breast cancer, making this the first differential diagnosis that should be considered.
2. Ectopic pregnancy: Possible amenorrhea, an increase in abdominal girth, increased urinary frequency, and nausea in a patient that uses the calendar method for contraception all suggest pregnancy. The dull lower abdominal pain followed by sudden-onset sharp pain and the tenderness to palpation in the right lower quadrant make an ectopic pregnancy likely. While this diagnosis needs to be ruled out, possible ovarian cancer should be investigated first because of the patient's family history.
3. Ruptured ovarian cyst: Sudden-onset sharp lower abdominal pain that starts during or following exercise is often caused by a ruptured ovarian cyst. The condition is particularly common in patients between 18–35 years of age, such as this woman. However, an ovarian cyst would not explain this patient's history of dull abdominal pain for 3 weeks or her other symptoms (nausea, increased urinary frequency, etc.), which is why it is listed as the third differential diagnosis here.

Diagnostic studies

• Pelvic examination: mandatory in all cases in which the chief complaint is gynecological
• Serum β-hCG: can detect a pregnancy on average 6–9 days after fertilization and has a higher sensitivity than urine β-hCG test
• CBC: to assess for possible anemia due to cancer or acute blood loss because of cyst rupture
• Transvaginal ultrasound: may show free fluid in cases of a ruptured ovarian cyst; can show extrauterine pregnancies and ovarian pathologies such as ovarian cancer or ovarian cysts
• Transabdominal ultrasound: may show free fluid in cases of a ruptured ovarian cyst; can show extrauterine pregnancies and ovarian pathologies such as ovarian cancer or ovarian cysts.
• Laparoscopy: to obtain a histologic sample in suspected ovarian cancer; can also be used to treat ovarian cancer and ectopic pregnancies.

Other differential diagnoses to consider

• Pregnancy
• Missed abortion
• Ovarian torsion
• Acute appendicitis
• Tubo-ovarian abscess