Family Medicine

19 year-old Female with Abdominal Pain

Brittani Jackson on Jan 27, 2015

Ms. Winters is a 20-year-old G2P2 with no significant past medical history, who presents to Family Medicine Clinic wth abdominal pain. She was in her usual state of good health until 4 days ago when she noted dull lower abdominal pain as well as burning with urination. She woke up today feeling as if she had been "hit by a bus". Today she is experiencing a subjective fever, chills and nausea in addition to her prior symptoms. She denies vomiting and diarrhea. She also denies vaginal discharge, irritation or odor. She states she is not currently sexually active. Her last menstrual period was 2 weeks ago.

Ob/Gyn History: Two uncomplicated pregnancies and vaginal deliveries at age 17 and 19. Menarche at age 13. Periods are regular. History of chlamydia at age 16. No pap smears. 

Past Medical History: None

Past Surgical History: None

Meds: None

Allergies: None

Social History: Waitress. Denies alcohol or illicit drug use.

Family History: Non-contributory.

PHYSICAL EXAM: 

Vitals: T 101.2, BP 112/28, HR 104, RR 12

Young, uncomfortable appearing woman sitting on exam table. MMM. Tachycardia without m/r/g. Lungs CTAB. Abdomen soft, non-distendied with mild suprapubic and moderate CVA tenderness (R>L). 

Which of the following is an appropriate next step in management?

Select all that apply
Expand all answers
Urine dipstick and micro
Yes. Given the high likelihood of UTI, a UA should be performed.


Pregancy test
Yes. In women of reproductive age, pregnancy status is critical in forming an appropriate differential. It is also important because pregnancy changes diagnostic approach in that radiation exposure must be avoided.


ED referral
No. The patient is hemodynamically stable. She does not require ED referral at this time.


GC/Chlamyda test
Yes. Despite her stating that she is not currently sexually active, STI is still a consideration. Testing for gonorrhea and chlamydia should be performed.


Pelvic ultrasound
No. Imaging can be deferred pending the results of the pregnancy test. Most women with acute pyelonephritis do not need imaging studies unless symptoms do not improve or there is a recurrence.


  • Evaluation of Abdominal Pain in Female patients of Child-bearing Age

    Image obtained from: http://www.aafp.org/afp/2008/0401/p971.html

Ms. Winters' UA demonstrates marked pyuria, positive leukocyte esterase and positive heme. Pregnancy test is negative. You suspect acute pyelonephritis. What is the appropriate next step in management?

Expand all answers
Treat as an inpatient
No. Given that the patient is relatively well-appearing, hemodynamically stable, and lacks co-morbid conditions, she can be treated as an outpatient. If any of these conditions were not met, or in the setting of pregnancy, male sex, toxic appearance, very high fever (>103 F), and/or inability to tolerate PO, admission is required.


Treat as an outpatient
Yes. Given that the patient is relatively well-appearing, hemodynamically stable, and lacks co-morbid conditions, she can be treated as an outpatient. If any of these conditions were not met, or in the setting of pregnancy, male sex, toxic appearance, very high fever (>103 F), and/or inability to tolerate PO, admission is required.


Obtain a abdominal ultrasound
No imaging is necessary at this time.


Obtain a transvaginal ultrasound
No imaging is necessary at this time. Transvaginal ultrasound should be performed in the setting of a positive pregnancy test.


Ms. Winters is a 20-year-old G2P2 with no significant past medical history, who presents to Family Medicine Clinic wth abdominal pain. She was in her usual state of good health until 4 days ago when she noted dull lower abdominal pain as well as burning with urination. She woke up today feeling as if she had been "hit by a bus". Today she is experiencing a subjective fever, chills and nausea in addition to her prior symptoms. She denies vomiting and diarrhea. She also denies vaginal discharge, irritation or odor. She states she is not currently sexually active. Her last menstrual period was 2 weeks ago.

Ob/Gyn History: Two uncomplicated pregnancies and vaginal deliveries at age 17 and 19. Menarche at age 13. Periods are regular. History of chlamydia at age 16. No pap smears. 

Past Medical History: None

Past Surgical History: None

Meds: None

Allergies: None

Social History: Waitress. Denies alcohol or illicit drug use.

Family History: Non-contributory.

PHYSICAL EXAM: 

Vitals: T 101.2, BP 112/28, HR 104, RR 12

Young, uncomfortable appearing woman sitting on exam table. MMM. Tachycardia without m/r/g. Lungs CTAB. Abdomen soft, non-distendied with mild suprapubic and moderate CVA tenderness (R>L). 

Which of the following is an appropriate next step in management?

Select all that apply
Expand all answers
Urine dipstick and micro
Yes. Given the high likelihood of UTI, a UA should be performed.


Pregancy test
Yes. In women of reproductive age, pregnancy status is critical in forming an appropriate differential. It is also important because pregnancy changes diagnostic approach in that radiation exposure must be avoided.


ED referral
No. The patient is hemodynamically stable. She does not require ED referral at this time.


GC/Chlamyda test
Yes. Despite her stating that she is not currently sexually active, STI is still a consideration. Testing for gonorrhea and chlamydia should be performed.


Pelvic ultrasound
No. Imaging can be deferred pending the results of the pregnancy test. Most women with acute pyelonephritis do not need imaging studies unless symptoms do not improve or there is a recurrence.


  • Evaluation of Abdominal Pain in Female patients of Child-bearing Age

    Image obtained from: http://www.aafp.org/afp/2008/0401/p971.html

Ms. Winters' UA demonstrates marked pyuria, positive leukocyte esterase and positive heme. Pregnancy test is negative. You suspect acute pyelonephritis. What is the appropriate next step in management?

Expand all answers
Treat as an inpatient
No. Given that the patient is relatively well-appearing, hemodynamically stable, and lacks co-morbid conditions, she can be treated as an outpatient. If any of these conditions were not met, or in the setting of pregnancy, male sex, toxic appearance, very high fever (>103 F), and/or inability to tolerate PO, admission is required.


Treat as an outpatient
Yes. Given that the patient is relatively well-appearing, hemodynamically stable, and lacks co-morbid conditions, she can be treated as an outpatient. If any of these conditions were not met, or in the setting of pregnancy, male sex, toxic appearance, very high fever (>103 F), and/or inability to tolerate PO, admission is required.


Obtain a abdominal ultrasound
No imaging is necessary at this time.


Obtain a transvaginal ultrasound
No imaging is necessary at this time. Transvaginal ultrasound should be performed in the setting of a positive pregnancy test.


388  views

  0 likes

      0 comments