A 28-year-old woman comes to the emergency department due to severe right lower quadrant pain. Yesterday, the patient noticed intermittent right lower abdominal pain associated with increased activity. She rested the remainder of the day, but the pain continued to increase. An hour ago, the pain suddenly became constant, severe, and associated with nausea and vomiting. The pain does not radiate. Temperature is 37.2 C (99 F), blood pressure is 130/80 mm Hg, and pulse is 98/min. There is tenderness to palpation over the right lower quadrant with no rebound or guarding. Urine pregnancy test is negative. Which of the following additional information would be most helpful in establishing this patient's diagnosis?

Question

A 28-year-old woman comes to the emergency department due to severe right lower quadrant pain.  Yesterday, the patient noticed intermittent right lower abdominal pain associated with increased activity.  She rested the remainder of the day, but the pain continued to increase.  An hour ago, the pain suddenly became constant, severe, and associated with nausea and vomiting.  The pain does not radiate.  Temperature is 37.2 C (99 F), blood pressure is 130/80 mm Hg, and pulse is 98/min.  There is tenderness to palpation over the right lower quadrant with no rebound or guarding.  Urine pregnancy test is negative.  Which of the following additional information would be most helpful in establishing this patient's diagnosis?

Quizplus · Accepted Answer

11ec25c8_d1e2_a151_bc81_9be382073b19_MD0003_00 In nonpregnant women, acute lower abdominal pain can have various causes involving the gastrointestinal, gynecologic, or urologic systems due to the proximity of their structures. Many of these causes have classic presenting symptoms that characterize the disease process and differentiate the diagnosis. This patient's right lower quadrant pain is classic for ovarian torsion, which occurs due to rotation of the ovary around the infundibulopelvic ligament, causing ovarian vessel occlusion. Although ovarian torsion can occur in all reproductive-aged women, those with a history of ovarian cysts (eg, hemorrhagic cyst) or masses (eg, mature cystic teratoma) are at increased risk because the greater size and density of the ovary make it prone to rotation and subsequent torsion. Patients initially have intermittent pain associated with activity (as in this patient) due to partial ovarian torsion; the pain resolves when the adnexa spontaneously untwists and blood flow returns. When this progresses to complete ovarian torsion, patients typically develop sudden-onset, severe, nonradiating pain (due to persistent ischemia) often associated with nausea and vomiting. rotation of the ovary Ovarian torsion can be diagnosed clinically, but a Doppler ultrasound is usually performed to evaluate ovarian blood flow and confirm the diagnosis. Treatment is with surgical detorsion to prevent ovarian necrosis; cystectomy/oophorectomy may be required. (Choice A) Associated urinary symptoms can help establish a urologic cause (eg, pyelonephritis, nephrolithiasis) of acute right lower quadrant pain. However, patients with urologic conditions typically have suprapubic or flank pain that radiates to the right lower quadrant, making this diagnosis less likely. (Choice B) A family history of malignancy usually does not aid in the diagnosis of acute lower abdominal pain. Although some ovarian cancers are inherited, patients with ovarian cancer typically have a chronic, indolent course with associated weight loss, early satiety, and abdominal distension. (Choice D) Having multiple sexual partners is a risk factor for sexually transmitted infections and pelvic inflammatory disease, which can cause lower abdominal pain. However, patients typically have fever; constant, diffuse pelvic pain; and associated rebound and guarding. (Choice E) Recent sick contacts are a risk factor for gastroenteritis, which can present with nausea, vomiting, and abdominal pain; however, patients typically have diffuse, cramping abdominal pain that gradually increases; persistent vomiting; and diarrhea. Educational objective: Ovarian torsion typically causes intermittent lower abdominal pain followed by sudden-onset, severe, nonradiating unilateral pain with associated nausea and vomiting. Ovarian torsion can occur in all reproductive-aged women, particularly those with a history of ovarian cysts. References: Clinical risk factors for ovarian torsion. (http://www.ncbi.nlm.nih.gov/pubmed/26212687) Adnexal torsion: review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/24126258)

A 28-Year-Old Woman Comes to the Emergency Department Due to Severe