A 37-year-old woman is brought to the emergency department by her boyfriend for severe abdominal pain that started several hours ago. The pain started diffusely in the periumbilical area but is now mostly localized to the lower abdomen. The patient has persistent nausea but no vomiting. Her last menstrual period was 25 days ago, but she has irregular periods. She is sexually active with her boyfriend. Her temperature is 36.8 C (98.1 F), blood pressure is 130/80 mm Hg, pulse is 110/min, and respirations are 25/min. The abdomen, especially in the lower quadrants, is tender on palpation with mild guarding. There is no shifting dullness. Bowel sounds are diminished. Laboratory results are as follows: Which of the following is the most appropriate next step in management of this patient?

Question

A 37-year-old woman is brought to the emergency department by her boyfriend for severe abdominal pain that started several hours ago.  The pain started diffusely in the periumbilical area but is now mostly localized to the lower abdomen.  The patient has persistent nausea but no vomiting.  Her last menstrual period was 25 days ago, but she has irregular periods.  She is sexually active with her boyfriend.  Her temperature is 36.8 C (98.1 F), blood pressure is 130/80 mm Hg, pulse is 110/min, and respirations are 25/min.  The abdomen, especially in the lower quadrants, is tender on palpation with mild guarding.  There is no shifting dullness.  Bowel sounds are diminished.  Laboratory results are as follows:  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient has acute-onset abdominal pain with a variety of possible etiologies, including gastrointestinal (GI) (eg, peptic ulcer disease, appendicitis, bowel obstruction or perforation), genitourinary (eg, kidney stone, ectopic pregnancy, ovarian torsion, pelvic inflammatory disease), vascular (eg, bowel ischemia), and musculoskeletal. Her last menses was 25 days ago, and she is sexually active with her boyfriend. She needs further evaluation to differentiate these etiologies, which may require imaging. A pregnancy test should be performed first as early pregnancy can present with GI symptoms including nausea, vomiting, abdominal bloating, and constipation. In addition, pregnancy should be excluded before exposing this patient to any tests involving radiation (eg, x-ray, CT scan). An embryo exposed to ionizing radiation during the first 14 days after conception may survive undamaged, but is often severely injured and subsequently resorbed. Further, exposure after the first 14 days frequently leads to developmental defects. A serum quantitative pregnancy test is very sensitive, and can be positive within 4 days of implantation; the urine pregnancy test can be negative for a week before becoming positive. If the pregnancy test is positive, this patient will require a pelvic ultrasound (Choice C) to evaluate for an intrauterine or ectopic pregnancy. Pelvic ultrasound can also be helpful for evaluating ovarian pathology. If the pregnancy test is negative, abdominal CT can be considered to evaluate possible appendicitis or kidney stones (Choice A). Abdominal x-ray (Choice E) may also then be considered to rule out intestinal obstruction or perforation (free air under the diaphragm). (Choice B) Diagnostic peritoneal lavage is an invasive procedure to evaluate for intraabdominal bleeding and is performed primarily on patients with trauma. It is not indicated in this patient. Educational objective: A pregnancy test should be administered to any woman of childbearing age before performing any diagnostic tests such as x-rays or CT scans that involve ionizing radiation. References: Radiation effects on development (http://www.ncbi.nlm.nih.gov/pubmed/17963274)

A 37-Year-Old Woman Is Brought to the Emergency Department by Her