A 33-year-old woman comes to the emergency department due to abdominal pain. The pain began 2 weeks ago and was initially mild, episodic, confined to the right lower quadrant, and resolved spontaneously without intervention. For the past 6 hours, the pain has been severe, constant, unrelieved by ibuprofen or acetaminophen, and radiating to the right flank. The pain is now accompanied by constant nausea and multiple episodes of emesis. The patient has had no diarrhea or recent travel. She has no chronic medical conditions but did have an appendectomy. The patient was treated for Chlamydia trachomatis cervicitis as a teenager. She is not currently sexually active. She does not use tobacco, alcohol, or illicit drugs. Temperature is 38 C (100.4 F), blood pressure is 130/80 mm Hg, pulse is 83/min, and respirations are 16/min. Abdominal examination shows tenderness and guarding in the right lower quadrant but no suprapubic or costovertebral angle tenderness. Pelvic examination shows a small, nontender, retroverted uterus and a tender right adnexal mass. Speculum examination is normal. Urine pregnancy test is negative. Which of the following is the best next step in management of this patient?

Question

A 33-year-old woman comes to the emergency department due to abdominal pain.  The pain began 2 weeks ago and was initially mild, episodic, confined to the right lower quadrant, and resolved spontaneously without intervention.  For the past 6 hours, the pain has been severe, constant, unrelieved by ibuprofen or acetaminophen, and radiating to the right flank.  The pain is now accompanied by constant nausea and multiple episodes of emesis.  The patient has had no diarrhea or recent travel.  She has no chronic medical conditions but did have an appendectomy.  The patient was treated for Chlamydia trachomatis cervicitis as a teenager.  She is not currently sexually active.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 38 C (100.4 F), blood pressure is 130/80 mm Hg, pulse is 83/min, and respirations are 16/min.  Abdominal examination shows tenderness and guarding in the right lower quadrant but no suprapubic or costovertebral angle tenderness.  Pelvic examination shows a small, nontender, retroverted uterus and a tender right adnexal mass.  Speculum examination is normal.  Urine pregnancy test is negative.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf01_80f1_8f63_5b27f88c8bd2_MD0005_00 This patient's presentation of right-sided pelvic pain with a tender adnexal mass is concerning for ovarian torsion, a surgical emergency that typically affects reproductive-age women. Ovarian torsion is the partial or complete rotation of the ovary around the infundibulopelvic (suspensory ligament of the ovary) and utero-ovarian ligaments, which can affect ovarian blood supply as the ovarian vessels travel in the infundibulopelvic ligament. Right-sided torsion is more common due to the greater length of the right utero-ovarian ligament and because the rectosigmoid colon occupies the space around the left ovary. Risk factors for torsion include pregnancy, ovulation induction during infertility treatment, and ovarian masses >5 cm. Ovarian torsion Patients usually develop intermittent pelvic pain followed by an acute onset of moderate to severe pelvic pain, nausea, and vomiting. Fever and leukocytosis indicate possible adnexal necrosis. Pelvic examination may reveal a palpable tender adnexal mass. Initial evaluation includes complete blood count, electrolytes, and serum β-hCG (to exclude ectopic pregnancy). First-line imaging is a pelvic ultrasound with color Doppler, which typically reveals an enlarged, edematous ovary with impaired ovarian blood flow. Management includes detorsion with emergent surgery, which also provides a definitive diagnosis. Salpingo-oophorectomy is reserved for obvious adnexal necrosis or suspected ovarian malignancy. Untreated torsion may lead to chronic pelvic pain and infertility. (Choices A, B, and C) Risk factors for pelvic inflammatory disease (PID) and a tubo-ovarian abscess include multiple sex partners, younger age (15-25), and prior history of PID. Patients with a tubo-ovarian abscess typically present with fever, purulent cervical discharge, and cervical motion or uterine tenderness, which are not seen in this patient. Diagnostic evaluation includes chlamydia and gonorrhea nucleic acid amplification testing. Management of a tubo-ovarian abscess includes intravenous antibiotics and possible CT-guided aspiration, which may be used to drain a small, unilocular pelvic abscess and guide antibiotic therapy. (Choice D) Although analgesia is important for patients with pain, ovarian torsion must be evaluated prior to discharging the patient due to the risk of ischemia resulting in loss of ovarian function. Educational objective: Ovarian torsion typically occurs in reproductive-age women and presents with sudden onset of unilateral pelvic pain and a tender adnexal mass. First-line imaging is a pelvic ultrasound with color Doppler, which typically shows an enlarged, edematous ovary with decreased blood flow. References: Adnexal torsion: review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/24126258) Sonographic diagnosis of ovarian torsion: accuracy and predictive factors. (http://www.ncbi.nlm.nih.gov/pubmed/21876091)

A 33-Year-Old Woman Comes to the Emergency Department Due to Abdominal