20: 28-year-old woman with abdominal pain

Question 1

Obstetrical History

Answer 1

G
Gravida or number of pregnancies
T
Number of Term pregnancies
P
Number of Preterm infants
A
Number of spontaneous or induced Abortions
L
Number of Living children

Question 2

Women who were victimized by their intimate partner are more likely to experience:

Answer 2

• -Migraines, frequent headaches
• -Chronic pain syndrome
• -Heart and blood pressure problems Arthritis
• -Stomach ulcers, frequent indigestion, diarrhea, constipation, irritable bowel syndrome, spastic colon
• -Pain during sex (dyspareunia), dysmenorrhea, vaginitis, pelvic inflammatory disease, chronic pelvic pain syndrome, and other gynecological diagnoses
• -Invasive cervical cancer and preinvasive cervical neoplasia
• -Depression, anxiety and post-traumatic stress
• -Unexplained or poorly explained findings on physical exam

Question 3

Red flags for intimate partner violence include:

Answer 3

• -Delay in seeking medical care
• -Non-compliance with treatment plan
• -Partner insisting on staying close and answering questions directed to patient
• -Hesitancy in answering questions or inconsistent or incorrect answers given to questions
• -Shyness or reticence in answering questions

Question 4

Facilitating Discussion About Domestic Violence

Answer 4

Ask screening questions
Create a safe setting
Interview the pt alone
Ensure confidentiality
Direct assessment
Know your local laws
Facilitate impartiality
Listen non-judgmentally

Question 5

Intimate Partner Violence Safety Assessment

Answer 5

1. Increasing severity of violence
2. Presence of gun in the house
3. Threats to kill or commit suicide by either victim or abuser
4. Use of drugs or alcohol by victim or abuser
5. Victim trying to leave or left recently
6. Harm to children

Question 6

Increasing Severity of Intimate Partner Violence

Answer 6

1. Verbal abuse, insults, yelling
2. Throwing things, punching wall
3. Pushing victim or throwing things at victim 4. Slapping
4. Kicking, biting
5. Hitting with closed fist
6. Attempting strangulation
7. Beating up; punching with repeated blows 9. Threatening with weapon
8. Assault with weapon

Question 7

Documenting a Case of Suspected Domestic Violence

Answer 7

When documenting a history of abusive behavior, use the patient’s own words in quotes and fill in names after pronouns are used. Example: “then he (John Smith)…”. Use neutral language. Example: “patient states”, not “patient alleges” which may give a false impression of disbelief.

Give a detailed description of the patient’s appearance, behavioral indicators, injuries and stages of healing, and health conditions. If the patient consents, use photos to document injuries; one with a face included in the photo, and then close-ups of the injury. If photos are not possible, draw and describe injuries on a body map in blue ink as this is difficult to alter/reproduce. Document recommendations for support and follow-up as well as materials given to the patient.

Question 8

The Role of the Physician in the Care of a Victim of Domestic Violence

Answer 8

Acknowledge the abuse and health implications

support your pts decisions

address safety issues

practice cultural sensitivity

consider the impact of abuse on children and other valuable parties

Question 9

Recommended Studies for Evaluation of Abdominal Pain

Answer 9

pap smear-thin prep

KOH/saline wet prep

chlamydia/gonorrhea DNA probe

urine dipstick

urine pregnancy test

RPR

HIV

HPV

Pelvic US

Colposcopy

Gonorrhea culture

hCg beta sub

Question 10

Severe / Life-Threatening Causes of Abdominal Pain

Answer 10

Appendicitis: Patients with appendicitis often start with visceral pain which is dull and in the periumbilical region; within a short time it classically localizes (presents with) fairly acute onset of moderate to severe right lower quadrant pain. There is often a history of nausea and/or vomiting. There are usually some changes in the patient’s bowel movements.

Question 11

Hepatitis

Answer 11

Although not acutely life-threatening, hepatitis is very important to recognize and diagnose as it can be contagious and some forms of hepatitis can lead to liver cancer. Patients usually present with nausea, vomiting, diarrhea, light colored stools, and/or dark urine which is often described as cola- or tea-colored. Patients generally have fever and yellow discoloration of their eyes, skin and mucus membranes (jaundice). Patients may have abdominal pain, loss of appetite, and malaise. It is important to determine the source of the infection. The diagnosis can usually be made by physical exam. Laboratory tests are helpful in determining the exact diagnosis. Treatment of the acute illness is generally supportive care. The history may include heavy alcohol consumption, high-risk behavior such as IV drug use, foreign travel, or multiple sexual partners.

Question 12

Ovarian cyst

Answer 12

Patients with an ovarian cyst generally have lower abdominal pain and pelvic pain. The pain may be extremely severe, especially if there is a ruptured cyst. The pain may be so severe that the patient will present to the emergency room for evaluation at the time of rupture. The pain may persist for several weeks, and may be aggravated by intercourse or strenuous activity.

Question 13

Pancreatitis

Answer 13

Pancreatitis is generally a moderately severe to severe epigastric pain that often radiates to the back, and is accompanied by nausea, vomiting and anorexia. There is usually a history of excessive alcohol use/abuse or a family history of pancreatitis, although this can also be caused by gallstones, hypertriglyceridemia and other less common causes. If suspicion is high, laboratory tests (lipase, amylase) and imaging (abdominal ultrasound or CT scan) are needed to investigate further.

Question 14

Pelvic inflammatory disease

Answer 14

Patients with pelvic inflammatory disease (PID) might have abdominal or pelvic pain, which is worse with sexual intercourse or with activities such as running or jumping, which cause jarring of the pelvic organs. This diagnosis has significant morbidity, which increases with the severity of the disease and with the length of time to diagnosis. Studies show that approximately one in four women who had a single episode of PID later experienced tubal infertility, chronic pelvic pain, or an ectopic pregnancy, as a result of scarring and adhesions. Tubal adhesions leading to infertility have been reported to occur in 33% of women after their first episode of PID, and up to 50% after the second pelvic infection.

Question 15

nml pregnancy

Answer 15

Women who have normal pregnancies may experience some lower abdominal discomfort or pain as the uterus undergoes normal growth. This is more a diagnosis of exclusion, but you would not want to miss a pregnancy. Certain medications should not be given to women who are pregnant. Fetuses should not be exposed to radiation.

Question 16

ectopic pregnancy

Answer 16

Ectopic pregnancy is a medical emergency. Early medical treatment reduces the need for surgery, but if the fallopian tube is in danger of rupture, surgical intervention may be necessary. Patients present with divergent symptoms ranging from no pain and normal menses, to intense pain and irregular or absent menses. A good history, the physical exam and lab testing are crucial for this diagnosis. Imaging is also usually needed. You need the date of the patient’s last menstrual period (LMP), her menstrual history, most recent intercourse dates, types of contraception used in past few years, history of any vaginal or pelvic infections, and history of previous ectopic or normal pregnancies.

Question 17

trauma

Answer 17

A careful history is important in regard to trauma. Be aware of the patient’s body language and response to touch. Consider the consistency of the history with the exam. Have the patient undress and examine the patient thoroughly in a gown so that all areas can be visualized.

Question 18

Appendicitis

Answer 18

The hallmark symptom of appendicitis is right lower quadrant pain.

It is extremely important to perform a pelvic exam in patients with abdominal pain

The pelvic exam is often tender in a patient with an acute abdomen.

Patients with acute appendicitis will frequently give a history of having had some vomiting. They generally have nausea, loss of appetite, mild fever, and will usually have decreased stooling or constipation.

Question 19

Pelvic inflammatory disease (PID)

Answer 19

Cervical motion tenderness, known as a positive “chandelier sign” is considered pathognomonic of pelvic inflammatory disease (PID).

Women with pelvic infections often have mild menstrual irregularities.

Question 20

Normal pregnancy

Answer 20

Symptoms of nausea and vomiting could be caused by pregnancy.

Growth of the uterus and stretching of the broad ligaments during a normal pregnancy often causes mild to moderate discomfort in the lower abdomen.

Question 21

Ectopic pregnancy

Answer 21

Ectopic pregnancy can present with amenorrhea, abnormal vaginal bleeding, or regular menses.

Question 22

Trauma

Answer 22

Patients who are pregnant, or even those in whom there is the suspicion of pregnancy, are at increased risk for trauma related to intimate partner violence. Additionally, the stress of suffering intimate partner violence may cause irregular menses in some women. Abdominal pain and cramping may come not only from the inflicted trauma but also from somatization of stress. Bruises of various colors, denoting various stages of healing, can be seen on any part of the body, but are often present on the abdomen as this would cause trauma to a fetus and because they are less visible.

Question 23

Gastritis

Answer 23

Symptoms of gastritis can be exaggerated by stress/emotions, diet, medications (particularly nonsteroidal anti-inflammatory drugs) and other things that cause excess acid production.

Patients frequently give a history of tobacco or alcohol use.

Patients may state that spicy foods aggravate the pain.

Patients with inflammation of the stomach may have nausea and decreased appetite.

The bowels are usually not affected unless there is a component of irritable bowel syndrome and stress. In that case there may be either decreased or increased stooling.

Question 24

Irritable bowel syndrome

Answer 24

IBS (irritable bowel syndrome) typically causes a variety of symptoms which can include abdominal pain, loose stools, diarrhea, constipation, abdominal bloating, increased flatulence and mucus in stools.

IBS is a diagnosis of exclusion.

Symptoms of IBS can be brought on initially by a case of gastroenteritis and can be aggravated by stress, dietary changes or change in activity, and are often unpredictable.

Question 25

Vaginitis

Answer 25

Symptoms and complaints of patients with vaginitis vary depending on the cause of the
discharge. Vaginal discharge is watery to pasty, discomfort can vary from itching to burning, and there may or may not be dyspareunia and pelvic pain.

Pelvic or abdominal pain is typically less constant than with PID.

Risk for sexually transmissible infections widens the differential, and use and type of contraceptive impacts risk so an expanded history is needed in this case.

Examination of the discharge under the microscope and cervical cultures are generally needed.

Question 26

Gallbladder disease

Answer 26

Patients with gall bladder disease usually complain of pain in the right upper quadrant which may radiate to the right shoulder or right upper back.

The patient may have a history of oral contraceptive use.

The classic patient is characterized by “four Fs”: premenopausal (fertile), overweight (fat), middle-aged (forty), and female.

Symptoms are aggravated by fatty foods.

Question 27

IBD

Answer 27

Patients with inflammatory bowel disease (IBD) have abdominal pain, bloody diarrhea and frequent stooling.

The onset frequently occurs in the late 20’s or early 30’s.

IBD is diagnosed by small bowel endoscopy, colonoscopy flexible sigmoidoscopy, or barium enema.

Question 28

Peptic ulcer disease

Answer 28

While peptic ulcer disease (PUD) used to be associated with stress, diet, alcohol, and tobacco use – we now know that the majority of cases are caused by infection with Helicobacter pylori (H. pylori).

PUD can be caused by excessive use of non-steroidal anti-inflammatory medications as well.

Symptoms include a gnawing or burning or boring pain in the upper abdomen and can be accompanied by bloody emesis or tarry stools.

Question 29

UTI

Answer 29

Urinary tract infection (UTI) symptoms may include lower abdominal pain, burning with urination (dysuria) that worse at end of urinary stream (terminal dysuria), and can involve hematuria.

The onset of symptoms is frequently related to recent sexual intercourse.