Case 6: Pelvic pain

Opening scenario

Autumn Larsen, a 30-year-old female; , comes to the physician because of pelvic pain.

Vital signs

• Temperature: 99°F (37.2°C)
• Blood pressure: 124/69 mm Hg
• Heart rate: 70/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

• Appear tired.
• When the examinee asks you where the pain is located, point at the lower part of your abdomen.
• When the examinee presses on the lower part of your abdomen, say that it hurts a little bit.
• 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 “Does this mean I cannot get 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
• I have had stomach pain on and off for years.
• Location
• In my lower abdomen, right here.
• Intensity (on a scale from 0–10)
• It changes. Sometimes it is really bad, like a 6 or 8, and other times it is not there at all.
• Quality
• Crampy.
• Onset
• About 5 years ago.
• Precipitating events
• Nothing special happened back then.
• Progression/constant/intermittent
• It seems to be slowly getting worse. I do not have it all the time – maybe 6 days out of the month now. And I know it used to be less than that.
• Previous episodes
• I get it once a month for multiple days in a row.
• Radiation
• My back hurts then, too.
• Alleviating factors
• Ibuprofen helps. And a heating pad.
• Aggravating factors
• Well it definitely seems worse around when I have my period.
• Associated symptoms
• I am a little embarrassed to say this, but it also sometimes hurts when I have sex with my husband, which is awful because we have been trying so hard to get pregnant. But I just do not feel like having sex if it hurts.

The patient's difficulty become pregnant may have an underlying gynecological cause. A more detailed history and diagnostic workup are warranted!

Review of systems specific to dysmenorrhea

• Fever/chills
• No.
• Fatigue
• I have felt quite tired lately. I do not know if it is because of the stress of trying to get pregnant, or if there is something more serious wrong with me.
• Racing of the heart
• No.
• Shortness of breath
• No.
• Urinary problems
• No.
• Bowel problems
• When I am in pain, it also sometimes hurts to go to the bathroom.
• Appetite
• No.
• Weight changes
• No.

Past medical history, family history, social history

• Past medical history
• None.
• Allergies
• None.
• Medications
• I take ibuprofen when the pain is bad.
• Hospitalizations
• Never.
• Past surgical history
• No.
• Family history
• My mother had fibroids in her uterus. But she was older than I am when she was diagnosed.
• Work
• I am an attorney specializing in human rights.
• Home
• Happily married. Though we have had some marital stress since I graduated from law school and started traveling for work, while at the same time trying to get pregnant.
• Alcohol
• No.
• Recreational drugs
• No.
• Tobacco
• No.

Sexual history, OB/Gyn

• Sexually active
• Yes, with my husband.
• Number of partners over the past year
• Just my husband.
  • History of sexually transmitted infection
  • No.
  • Most recent screening for sexually transmitted infections
  • 3 years ago, before I got married.
• Last menstrual period
• Two weeks ago.
• Menarche
• I was 9 years old when I got my first period.
• Duration of period
• It is long and heavy. About 8 days, I would say.
• Period regular
• Yes, every 4 weeks.
  • Spotting
  • No.
• How many tampons per day
• Oh, I am not really sure, but I have to change them every 2 hours or so.
• Vaginal discharge
• Just the normal kind.
• Vaginal itching
• No.
• Vaginal dryness
• No.
• Pregnancies
• Not yet, but my husband and I have been trying for about 2 years now.
• Abortions/miscarriages
• No.
• Last Pap smear
• 5 months ago. They have always been normal.

Even though this patient is married, it is important to screen for potential sexually transmitted infections. Chlamydia genitourinary infections, for example, are commonly asymptomatic and can cause infertility in women.

• Washed hands
• Used respectful draping
• Head, eyes, ears, nose, and throat examination
  • Inspection of the conjunctivae
• Cardiovascular examination
  • Auscultation of the heart
• Abdominal examination
  • Inspection of the abdomen
  • Auscultation of the abdomen
  • Percussion of the abdomen
  • Palpation of the abdomen
    • Mild tenderness in the RLQ and LLQ

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 reacted appropriately to challenge.

Suggested response to challenge: “Ms. Larsen, I understand that you are very concerned about not getting pregnant despite trying. Unfortunately, it is not possible for me to say right now whether you will eventually get pregnant. However, the fact that you have been trying for 2 years without success tells me that it is time for us to look into the issue further. First, I would like to order some tests and do a pelvic examination to get a better idea of what could be going on. Then you and I can sit together and talk about what we find and what we still might need to do.”

Patient note

Differential diagnoses

1. Uterine leiomyoma: Chronic dysmenorrhea, menorrhagia, dyspareunia, dyschezia, primary infertility, and tenderness in the lower abdomen are all signs of uterine leiomyoma. This patient is also within the peak age range for uterine leiomyoma (25–45 years). Although these symptoms can also occur in endometriosis, this patient's family history of uterine fibroids as well as her predisposing factors for uterine leiomyoma (menarche before the age of 10, nulliparity) make this the most likely diagnosis.
2. Endometriosis: Chronic dysmenorrhea, menorrhagia, dyspareunia, dyschezia, primary infertility, and tenderness in the lower abdomen are also all signs of endometriosis, and the fact that palpation did not reveal uterine enlargement further supports this diagnosis. While this diagnosis should certainly be ruled out, the patient's family history and predisposing factors make uterine leiomyoma more likely, however.
3. Adenomyosis: Chronic dysmenorrhea, menorrhagia, and tenderness in the lower abdomen are common symptoms of adenomyosis. While early menarche is a risk factor for the condition, patients do not normally have primary infertility (multiparity is rather a risk factor) and dyspareunia and dyschezia are less commonly seen than in endometriosis and uterine leiomyoma, making this condition less likely than the other differential diagnoses.

Diagnostic studies

• Pelvic examination: should always be the first examination in patients with pelvic pain. Endometriosis would present with rectovaginal tenderness and adnexal masses; uterine leiomyoma would pesent with an irregular, enlarged, firm uterus; adenomyosis would present with a uniformly enlarged uterus.
• CBC: Because this patient has heavy menstrual bleeding and feels fatigued, it is important to assess for possible anemia.
• Urine β-hCG: Because this patient is trying to become pregnant, a pregnancy should be excluded before other more invasive tests such as a laparoscopy are performed.
• Transvaginal ultrasound: best initial imaging test in endometriosis, uterine leiomyoma, and adenomyosis
• Pelvic MRI: more accurate than transvaginal ultrasound; helps to differentiate between leiomyomas and adenomyosis
• Laparoscopy: Diagnostic laparoscopy and subsequent biopsy of a suspicious lesion allow for definitive diagnosis of endometriosis.

Other differential diagnoses to consider

• Endometritis
• Endometrial cancer
• Primary dysmenorrhea
• See also differential diagnosis and treatment of dysmenorrhea and menorrhagia and differential diagnoses of uterine leiomyoma.