Here’s how this is going to work. Thanks to a reader, I have a case for you, which I’ll present in parts. I will try to make the information accessible to both professionals and lay-people. I’ll start with the barest of information and rather than guess what’s going on right away, I’d like to see people organize their thoughts into broad categories based on the initial symptoms. One way to think about this is to think about what, anatomically, is in the area of question—in other words, what can go wrong there. Then, think of types of disease—vascular, anatomic, infectious, allergic, etc. I will, of course, help you with this.
A 32 year old woman presents to the emergency department with a chief complaint of abdominal pain. She reports that the pain is in her lower abdomen. It began as a vague, dull ache about one week prior to presentation but now it is sharp, severe, and does not radiate. Nothing seems to make it better or worse.
So think about what structures could be affected and by what mechanism. If you guys can’t come up with it, I’ll give you an example. After a while, I’ll addend this post with a summary of the comments and the next set of findings.
I really shouldn’t do this without providing an example, so I’ll start off a bit for you so you see how to approach this.
Lower abdominal pain can be due to (but not necessarily limited to) some of the following structures:
- Large intestine
- Small intestine
- Iliac artery or other large arteries branching off the aorta
- Female reproductive tract, including ovaries, fallopian tubes, uterus
- round ligament
- referred pain from somewhere else, and anything else I might have forgotten
One or more of these structures may be affected by one of these general processes(incomplete list):
Once we complete this “Templeton Grid” (more on that later) we can fill in some possibilities.
Strong work by all. Good questions, good ideas. Most of my medical students and interns like to jump right to guessing a diagnosis, but I tell them to hold up. If you jump to conclusions before you systematically approach the case, you’re going to make mistakes, and so while all of the guesses were excellent, they are premature.
Dianne’s response is a typical one from someone with a good medical education. Once you have a fairly comprehensive list like that, you can gather more information and start to cross things off.
When I present a case, I like to give data out in the order real life would allow. So…
On further questioning, the patient has no significant family history of medical problems. She herself has no history of medical problems. Her last period was five weeks ago. She doesn’t smoke and drinks alcohol and uses marijuana from time to time. She doesn’t take any medications.
The patient appears to be in mild distress due to pain.
Her heart rate is 108, respirations are normal, blood pressure is 165/90. Her temperature is 37.8 C. She weighs 90kg.
She isn’t jaundiced. She is not emanating any unusual odors. Her mouth is moist. She is not pale. Her heart was regular but fast. Her lungs were clear. Her legs were not swollen. Her abdomen was soft to the touch, but pushing on the lower abdomen caused her to tense up a bit. She was especially tender in across the lower abdomen, perhaps slightly more on the right. On rectal exam, she has normal brown stool which does not have any trace blood in it.
Some time has passed and some of the investigations you’ve asked for are available.
A urine pregnancy test is negative. A white blood cell count is 10.2 (slightly elevated). A urinalysis shows no blood, no pus, and no other abnormalities. Standard blood chemistries were normal.
I would use this information to cross out some of the possibilities that Dianne outlined.
After presenting the case to your attending physician, she reminded you to do a pelvic exam. On exam, there was physiologic (normal) vaginal discharge, and normal external genitalia. Her cervix was grossly normal. There was tenderness of the adnexa (ovaries and tubes) and some minimal tenderness when the cervix was moved around. Slides of the vaginal secretions were normal (pH 4.5, no hyphae, no trichomonads, no clue cells).
We’ve been narrowing things down to a few basic structures. Here they are:
Human appendix ( (Source)
Female reproductive tract
The classic teaching of appendicitis is that the os of the appendix becomes obstructed with fecal material, and in the human body, stasis often leads to infection. When the appendix becomes blocked and infected, the patient often develops vague lower abdominal pain around the navel which eventually migrates to a point between the navel and the right hip. Appetite declines, bowel movements stop, and the patient gets very sick.
Ovarian torsion involves an ovary turning around on it’s stalk with the blood flow being cut off. It’s usually unilateral and very painful.
Pelvic inflammatory disease, a common complication of gonorrhea and chlamydia, causes lower abdominal pain, fevers, and tenderness of the cervix and ovaries. Sometimes an abscess forms and you can feel a discrete mass.
Endometriosis tends to come and go with periods and the pain can be nearly anywhere.
Ovarian cysts, physiologic or otherwise, can get worse peri-menstrurally, and can even rupture.
In this case, an ultrasound showed some free fluid in the pelvis, normal blood flow to the ovaries, and some fullness to the tubes and ovaries, including what appeared to be a large, ruptured cyst on the right. There was no intrauterine or extrauterine pregnancy.
A CT scan of the abdomen and pelvic showed a normal vermiform appendix and was otherwise normal.
A genetic probe for Neisseria gonhorroeae and Chlamydia trachomatis came back positive for the latter.
This tells me two things: the pain may be due to a ruptured ovarian cyst (a benign condition) or to pelvic inflammatory disease (PID), which can lead to infertility. Given the opportunity, I would treat the pain of the cyst, and treat the PID with a long-ish course of antibiotics according to current guidelines. I would counsel the patient to speak to any sexual partners about her diagnosis and provide counseling on STD prevention and contraception. I would also check her blood for syphilis and HIV, and perhaps hepatitis B.