22: 16-year-old female with abdominal pain

Question 1

acute appendicitis

Answer 1

Acute appendicitis is the most common condition requiring emergency surgery in the pediatric population.

Question 2

Testicular Torsion CP

Answer 2

• Usually occurs in early adolescence and presents with acute onset of severe hemi-scrotal pain, nausea, and vomiting. May cause referred abdominal pain.
• Physical examination reveals an enlarged tender testis, scrotal edema, and absence of the cremasteric muscle reflex.

Question 3

Testicular Torsion: Prompt Intervention

Answer 3

• -If torsion is suspected, an emergent urology consult is indicated.
• -The diagnosis is made mainly by clinical suspicion.
• -Color Doppler ultrasound or nuclear testicular scan may be useful but should not delay treatment if the diagnosis is evident.
• -Surgical exploration and detorsion must occur promptly, because irreversible changes in the testis can occur within four hours.

Question 4

PID Minimum criteria

Answer 4

• cervical motion tenderness
• uterine tenderness
• adnexal tenderness
• Supportive Criteria (enhance specificity of minimum criteria): oral temperature > 101 F (38.3 C)
• abnormal cervical mucopurulent discharge or cervical friability
• presence of abundant numbers of WBC on saline microscopy of vaginal fluid elevated
• ESR
• elevated CRP
• laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis

Question 5

Sexually active females ages 15 to 19 years are at highest risk because of both biological and behavioral factors:

Answer 5

• -At this age, there are fewer protective antibodies in the vagina (compared to those in older women).
• -Another reason is the cervical ectropion which represents the transitional zone between the columnar and the squamous epithelium is not fully matured; cells in this zone are particularly susceptible to STDs, and the cervix is therefore easier to infect.
• -Behavioral factors include intercourse during menses, infrequent or no condom use, and multiple sexual partners.

Question 6

A useful mnemonic to help remember the key elements for any pain history is PQRST AAA

Answer 6

P = Position (be exact)
Q = Quality (dull, sharp, burning)
R = Radiation (be exact)
S = Severity (scale from 1 to 10, if the patient can do this) 
T = Timing (when it happens)
A = Alleviating factors
A = Aggravating factors
A = Associated symptoms

Question 7

Antibiotics Therapy for Pelvic Inflammatory Disease

Answer 7

• -Ceftriaxone provides adequate coverage for gonorrhea and Doxycycline for chlamydia, but neither should be used as single agent therapy for PID. Empiric therapy should provide broad coverage of all likely pathogens.
• -CDC recommends that anaerobic coverage with metronidazole should be considered in all pts with PID. Anerobes have been isolated from the upper reproductive tract of women with PID and may contribute to the development of long-term sequelae (ectopic pregnancy, infertility, chronic abdominal pain, increased risk of recurrent PID).

Question 8

The decision to hospitalize a patient diagnosed with pelvic inflammatory disease should be individualized. Reasons to hospitalize a patient include

Answer 8

• Pregnancy
• Previous noncompliance
• High fever
• Intractable vomiting
• Inability to exclude a surgical emergency
• Inadequate response on oral therapy within 72 hours
• Tubo-ovarian abscess

Question 9

All states require reporting of STIs

Answer 9

including chlamydia, gonorrhea, syphilis, and chancroid.

Question 10

Differential Diagnosis of Abdominal Pain and Vomiting: Appendicitis

Answer 10

• Always consider in a child or adolescent with acute abdominal pain.
• Classic pattern (60% of the time) is periumbilical pain followed by generalized RLQ abdominal pain. Diffuse abdominal tenderness is possible (as in the case of peritonitis due to a ruptured appendix).
• Vomiting is very common; while diarrhea is uncommon (typically patients have had no bowel movements in the past several hours).
• Although fever is often seen with appendicitis, it is a non-specific finding.
• Tenderness over McBurney’s point is commonly seen in adults, but less frequently found in children.

Question 11

Differential Diagnosis of Abdominal Pain and Vomiting: Cholecystitis

Answer 11

• Pain, most often in the RUQ, is steady, and may radiate to the shoulder.
• Pain is usually constant and worse after eating, especially fatty foods.
• Episodes may be intermittent (colicky) and accompanied by decreased appetite, nausea, and vomiting.
• Cholecystitis is less common in children than in adults, but does occur.
• Murphy’s sign (increased pain upon palpation of the area when the patient takes a deep breath) is a finding specific for cholecystitis.

Question 12

Differential Diagnosis of Abdominal Pain and Vomiting: Pregnancy

Answer 12

• -Teen pregnancy usually presents with delayed or missed periods and must be considered even when sexual activity is denied during the history.
• -Often patients present with nonspecific complaints: lower abdominal pain, urinary frequency, fatigue, nausea and vomiting.
• -On speculum exam you might appreciate a bluish color of the vaginal wall and cervix (Chadwick’s sign), changes to the uterus depend on weeks of gestation.
• -Ectopic pregnancy must be considered in teens, especially with a history of STI alone or with pelvic inflammatory disease.
• -Unruptured ectopic pregnancy classically presents with lower abdominal pain, vaginal bleeding, and abnormal menstrual history. Physical examination may be completely normal, however classic signs are diffuse abdominal tenderness and unilateral adnexal or cervical motion tenderness. Fever and uterine changes are rare.
• -Ruptured ectopic pregnancies are a surgical emergency. On physical exam, abdominal guarding suggests intraperitoneal bleeding and hypotension correlates with the degree of blood loss.

Question 13

Differential Diagnosis of Abdominal Pain and Vomiting: Hepatitis

Answer 13

• Usually presents with fever, malaise, diffuse or RUQ abdominal pain, nausea, and vomiting without diarrhea.
• Patients will often comment on jaundice and a change in the color of their urine.
• Onset of symptoms depends on the etiology of the hepatitis
• Alcohol use may either directly cause hepatitis or predispose an individual to increased risk- taking behavior and the acquisition of infectious hepatitis, particularly Hepatitis B or C.
• Hepatitis A is transmitted via the fecal-oral route and therefore a history of recent travel would make this a possibility.
• Hepatomegaly is a common finding on physical examination.

Question 14

Differential Diagnosis of Abdominal Pain and Vomiting: Pancreatitis

Answer 14

• -May present with diffuse abdominal pain, but other patterns (such as epigastric or RUQ) are more common; band-like pain radiating to the back is highly suggestive.
• -Pain is constant and usually severe.
• -Nausea and vomiting are almost always present.
• -Low-grade fevers are common.
• -Causes of pancreatitis include gallbladder disease, infection, alcohol use, injury, certain medications, and inherited conditions.

Question 15

Differential Diagnosis of Abdominal Pain and Vomiting: PID

Answer 15

• Presents with abdominal pain in almost all cases, more typically in the lower abdomen; RUQ pain can occur with perihepatitis-Fitz-Hugh-Curtis syndrome-an occasional complication (5% of cases) of PID caused by N. gonorrhoeae or C. trachomatis (this pain is of sudden onset and may refer to the right shoulder)
• Fever is consistent with PID and vomiting is seen in some but not all cases of PID.
• Cervical motion tenderness, uterine tenderness and adnexal tenderness are highly suggestive (if not almost diagnostic!).
• Purulent cervical discharge is also highly suggestive.
• While a history of sexual activity makes PID much more likely (the highest rates of PID are in sexually active girls 15-19 years of age), PID must be considered in a young woman with acute abdominal pain, even if there is no history of sexual activity.

Question 16

Differential Diagnosis of Abdominal Pain and Vomiting: UTI

Answer 16

• UTIs in older children usually present with dysuria, frequency, and urgency.
• Poorly localized abdominal pain occasionally occurs with a UTI; fever or CVA tenderness suggests pyelonephritis if present. CVA tenderness is not a constant finding at any age.
• Previous history of UTIs may suggest underlying structural abnormalities that would increase the risk of infection.
• More common in sexually active women.

Question 17

Differential Diagnosis of Abdominal Pain and Vomiting: acute gastroenteritis

Answer 17

• Vomiting is a common presenting complaint in acute gastroenteritis.
• After a couple of days, diarrhea typically becomes the most pronounced symptom.
• May reveal history of sick contacts.

Question 18

Differential Diagnosis of Abdominal Pain and Vomiting: mesenteric adenitis

Answer 18

• Inflammation of the mesenteric lymph nodes.
• Has many causes and often presents like appendicitis.
• Typical presentation is of RLQ pain with fever, vomiting, and diarrhea.

Question 19

Differential Diagnosis of Abdominal Pain and Vomiting: ovarian torsion

Answer 19

• Can happen in any age group but is more common in post-menarchal women.
• Abdominal pain is a common symptom, often described as stabbing.
• Most typically occurs in the lower abdomen or pelvic region.
• N/v are also seen in the majority of patients.
• Every clinician should have a high index of suspicion for ovarian torsion when evaluating an adolescent female with acute abdominal pain. The standard of care is no longer oophorectomy but untwisting with ovarian salvage. Preservation of ovarian function and future fertility is most successful when the diagnosis is thought of early.

Question 20

A 16-year-old obese Caucasian female with a history of irregular menses presents to the ED with severe abdominal pain and altered mental status. She uses intravenous drugs weekly. She has regular unprotected sexual intercourse with multiple male sexual partners. She has experienced fevers, nausea, vomiting, and right shoulder pain and reports no vaginal bleeding. She has not regularly seen a physician for years. Only bedside studies are performed. Vitals are T 38.0 C, BP 90/60 mmHg, P 120 bpm, R 20 bpm. Qualitative B-hCG is positive, and hemoglobin is 7 g/dL. On exam, she is in apparent distress and has difficulty answering questions. Auscultation of the chest is clear. The abdomen is somewhat rigid with tenderness in the right lower quadrant as well as guarding and rebound tenderness. On pelvic exam, there is cervical motion tenderness but no bleeding or masses noted. What is the most likely diagnosis?

Answer 20

The patient likely has a ruptured right-sided ectopic pregnancy, as indicated by the positive pregnancy test and hemodynamic instability. Hemorrhage into the peritoneum may irritate the peritoneum and cause referred pain to the right shoulder. Cervical motion tenderness may also be found. Patients may experience nausea, vomiting, and fever.

Question 21

A 16-year-old female presents with acute onset of diffuse abdominal pain with periodic sharpness in the right upper quadrant that radiates to her back. She has had some episodes of vomiting and has a fever. She is sexually active and has used alcohol in the past. Which of the following is most likely to present with right upper quadrant pain?

Answer 21

Choice A is correct because pancreatitis commonly causes continuous abdominal pain that can localize to the right and left upper quadrants (“band-like pain”) as well as radiating to the back. Nausea and vomiting are nearly always present. Lipase is the most sensitive and specific lab test to diagnose pancreatitis.

appendicitis classically starts as periumbilical pain that migrates to McBurney’s point (1-2” from the anterior superior iliac spine toward the umbilicus). It is also of concern in a teenager with a presentation like this, as acute appendicitis is the most common pediatric condition requiring emergency surgery. Of children presenting with acute abdominal pain, 1-4% have appendicitis.

Question 22

A 16-year old female presents to the ED with abdominal pain. Upon questioning, the patient notes that the pain is pretty consistently in the RLQ without radiation. She denies dysuria, hematuria, or blood in the stool. She has a history of multiple sexual partners and inconsistent condom use. She does not use any other contraceptive measures. She believes her last menstrual period was 3 weeks ago, but she is unsure. She has no history of abdominal or pelvic surgeries. Her temperature is 100.8 F, heart rate is 85 bpm, respiratory rate is 12 bpm, and blood pressure is 110/70 mmHg. Her abdominal exam is notable for involuntary guarding, tenderness to palpation in the RLQ without rebound tenderness, and no CVA tenderness. Her pelvic exam is notable for cervical motion tenderness with some discharge. What is the best NEXT step in management?

Answer 22

A pregnancy test is the best first step in management. Pregnancy is one of the indications for inpatient management of PID, so this is very important information when determining whether to admit the patient from the ED or to provide outpatient treatment. While cervical cultures and empiric antibiotics are obviously a must when you suspect PID, pregnancy test is the first step, and the best answer.

Question 23

Luanne is a 15-year-old female who presents with three hours of abdominal pain and two episodes of non-bilious, non-bloody vomiting. She rates her pain at 8/10 and describes it as constant, located mainly in the middle of her belly but somewhat present throughout her abdomen. It is worse with coughing and moving. She has never had pain like this before, and has had no appetite since the pain started. She is sexually active with her boyfriend of three months, always uses condoms, and has not been tested for STIs. She is due to start her period next week. Vitals: 37.9 C, HR 100 bpm, BP 120/85 mmHg, RR 14 bpm. On exam, she exhibits involuntary guarding, mild rebound tenderness, and tenderness to palpation between her right anterior superior iliac spine and umbilicus. On pelvic exam, she reports tenderness when attempting to palpate her right adnexa, but no masses are appreciated and there is no cervical motion tenderness. Her WBC and CRP are within normal limits. Based on the information above, what is the most likely diagnosis?

Answer 23

Appendicitis is the most common condition in children requiring immediate surgical intervention, but often presents differently than in adults (especially in infants). Aspects of their atypical presentation include lack of migration of pain to the RLQ, negative Rovsing’s sign, and involuntary guarding and fever without perforation. In school-age children who can articulate the pain, they often describe pain with movement or coughing (cat’s eye sign). Also, rebound tenderness was found to be neither sensitive nor specific in the pediatric population, while in the adult population it is one of the most accurate PE findings (86%). Luanne is of the older pediatric population, and so will present with a more typical appendicitis. Her sudden onset of intense pain at the umbilicus with vomiting, anorexia, and tenderness at McBurney’s point are all classic findings. The more atypical signs include diffuse pain centered below the umbilicus, and rebound tenderness that might point to a perforation (more likely, it is part of the atypical pediatric presentation given her normal WBC study). Another atypical aspect of her exam is her adnexal pain during the pelvic exam, which could be due to the degree of inflammation and the positioning of her appendix. The key take-away point is to have a high index of suspicion for appendicitis for pediatric patients with abdominal pain given their atypical presentation.

Question 24

A 16-year-old homeless female presents with low-grade fever and abdominal pain. The patient reports recent unprotected sex. Abdominal examination reveals tenderness to palpation in the lower abdominal region, but no masses are appreciated. Pelvic examination reveals whitish cervical discharge and cervical motion tenderness. The discharge is sent for culture, and a pregnancy test is negative. What is the next best step in management?

Answer 24

This patient has signs and symptoms of PID. Cervical discharge should be tested for gonorrhea and chlamydia and sent for culture. As she is a homeless patient, she is at high risk for failure to complete her antibiotic course. Given the deleterious sequelae of incompletely treated PID, she should be hospitalized in order to ensure a full course of treatment.