A 16-year-old girl comes to the emergency department due to nausea and lower abdominal pain. The pain began yesterday but has become more severe over the past 12 hours. The patient describes the pain as "crampy" with periodic sharp and stabbing sensations. She has urinary frequency but no dysuria or hematuria. The patient has no appetite and vomited twice this morning. Her last bowel movement this morning was firm and nonbloody, but she still has a strong urge to defecate. The patient also started having vaginal spotting today. She has no medical history other than an episode of abnormal vaginal discharge 6 months ago that self-resolved. Menarche occurred at age 13, and the patient is unsure of her last menstrual period as they are irregular. Temperature is 36.7 C (98.1 F), blood pressure is 110/60 mm Hg, and pulse is 78/min. Examination shows tenderness to palpation in the left lower quadrant of the abdomen. Which of the following is the most likely explanation for this patient's condition?

Question

A 16-year-old girl comes to the emergency department due to nausea and lower abdominal pain.  The pain began yesterday but has become more severe over the past 12 hours.  The patient describes the pain as "crampy" with periodic sharp and stabbing sensations.  She has urinary frequency but no dysuria or hematuria.  The patient has no appetite and vomited twice this morning.  Her last bowel movement this morning was firm and nonbloody, but she still has a strong urge to defecate.  The patient also started having vaginal spotting today.  She has no medical history other than an episode of abnormal vaginal discharge 6 months ago that self-resolved.  Menarche occurred at age 13, and the patient is unsure of her last menstrual period as they are irregular.  Temperature is 36.7 C (98.1 F), blood pressure is 110/60 mm Hg, and pulse is 78/min.  Examination shows tenderness to palpation in the left lower quadrant of the abdomen.  Which of the following is the most likely explanation for this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d709_23d4_bc81_250407b0b448_MD0003_00 This patient's lower abdominal pain, vaginal spotting, and nausea/vomiting are concerning for an ectopic pregnancy, which occurs when a blastocyst implants in an extrauterine location. The most common (~96%) location is the fallopian tube; less common locations include the abdomen and cervix. Risk factors include prior ectopic pregnancy, tubal surgery, or sexually transmitted infection (eg, remote history of vaginal discharge) because these conditions can cause tubal scarring, obstructing normal blastocyst migration. fallopian tube locations Patients with an ectopic pregnancy typically develop vaginal bleeding and pelvic pain as the pregnancy outgrows the fallopian tube. An acute increase in pain may occur with tubal rupture, which can lead to hemoperitoneum with blood pooling in the posterior cul-de-sac, resulting in the urge to defecate (due to increased rectal pressure) and potential hemodynamic instability. Therefore, all reproductive-age women, including adolescents (who may be reluctant to disclose sexual activity), who have unexplained vaginal bleeding and abdominal pain require pregnancy testing. Pregnant patients require a transvaginal ultrasound to determine pregnancy location. tubal rupture (Choice A) Fitz-Hugh-Curtis syndrome (ie, perihepatitis) is characterized by an ascending upper genital tract infection involving the hepatic capsule; therefore, patients typically have right upper quadrant, not left lower quadrant, abdominal pain. (Choice C) Granulomatous inflammation of discontinuous small intestine segments occurs in Crohn disease. Patients may have crampy abdominal pain, diarrhea, and strong urges to defecate; however, there is no association with vaginal bleeding. (Choice D) Diverticulitis (ie, inflammation of a sac-like protrusion of the colonic wall) can present with left lower quadrant abdominal pain but does not cause vaginal spotting. In addition, this diagnosis is very uncommon in adolescents. (Choice E) Overgrowth of enteric bacteria within the bladder occurs with urinary tract infections (UTIs), which can present with urinary frequency. However, UTIs typically cause suprapubic or midline pain and are unlikely to cause nausea/vomiting. In addition, this diagnosis is less likely in this patient with no dysuria or hematuria. (Choice F) Intussusception (ie, telescoping of the intestines) can cause intermittent, colicky abdominal pain and currant jelly stools but not vaginal bleeding. In addition, this diagnosis usually presents in infants age 6-36 months. Educational objective: Ectopic pregnancy, which occurs when a developing blastocyst implants in an extrauterine location (eg, fallopian tube), can present with nausea/vomiting, pelvic pain, and vaginal bleeding. Therefore, all reproductive-age women with these symptoms require pregnancy testing. References: Current knowledge of the aetiology of human tubal ectopic pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/20071358) American Academy of Pediatrics. Clinical report--gynecologic examination for adolescents in the pediatric office setting. (http://www.ncbi.nlm.nih.gov/pubmed/20805151)

A 16-Year-Old Girl Comes to the Emergency Department Due to Nausea