AMBOSS CASES:

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.

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

o 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.

FOCUSED PHYSICAL EXAMINATION

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

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

Other ddx:

- Ectopic pregnancy (ruptured)

- Ruptured ovarian cyst