You will complete the Aquifer case, Internal Medicine 14: 18-year-old female for pre-college physical, focusing on the “Revisit three months later” for this assignment.
After completing the Aquifer case, you will present the case and supporting evidence in a PowerPoint presentation with the following components:
- Slide 1: Title, Student Name, Course, Date
- Slide 2: Summary or synopsis of Judy Pham’s case
- Slide 3: HPI
- Slide 4: Medical History
- Slide 5: Family History
- Slide 6: Social History
- Slide 7: ROS
- Slide 8: Examination
- Slide 9: Labs (In-house)
- Slide 10: Primary Diagnosis and 3 Differential Diagnoses – ranked in priority
Primary Diagnosis should be supported by data in the patient’s history, exam, and lab results.
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Order Paper Now- Slide 11: Management Plan: medication (dose, route, frequency), non-medication treatment, tests ordered, education, follow-up/referral.
- Slide 12-16: An evaluation of 5 evidence-based articles applicable to Ms. Pham’s case: evaluate 1 article per slide.
- Include title, author, and year of article
- Brief summary/purpose of the study
- How did the study support Ms. Pham’s case?
Course texts will not count as a scholarly source. If using data from websites you must go back to the literature source for the information; no secondary sources are allowed, e.g. Medscape, UptoDate, etc.
- Slide 17: Reference List
- You will submit the PowerPoint presentation in the Submissions Area by the due date assigned. Name your Case Study Presentation SU_NSG6430_W7_A2_lastname_
Family Medicine 20: 28-year-old female with abdominal pain User: Roxanne Barbe Email: rbarbe849@usuniversity.edu Date: May 23, 2020 4:36AM
Learning Objectives
The student should be able to:
Conduct a culturally sensitive, empathic history. Appreciate the ways in which victims of violence may manifest symptoms and be alert to clues a patient may give that he/she has been a victim of intimate partner violence. Discuss ways to assist the patient in developing a safety plan. Discuss reporting requirements for domestic violence. Appreciate a survivor’s perspective in an abusive relationship and the barriers to his/her seeking help. Apply knowledge of the differential diagnosis of abdominal and pelvic pain in evaluating the patient.
Knowledge
Significance of the Location of Abdominal Pain
The location of the abdominal pain is important, as it can help narrow your differential diagnosis. For example, diffuse abdominal pain may represent gastroenteritis, whereas localized right lower quadrant pain is classic for but not limited to appendicitis. Think about what is in the various quadrants of the abdomen when considering the differential diagnosis of abdominal pain.
Red Flags of Life-Threatening Condition in Patient with Abdominal/Pelvic Pain
There are more than many signs and symptoms of a life-threatening condition in a patient with abdominal or pelvic pain. Examples include:
Abrupt onset of severe pain Shock with hypotension and tachycardia Distension Peritoneal irritation signs Rigid abdomen Pulsatile abdominal mass Absent bowel sounds Fever Vomiting Diarrhea Weight loss Menstrual changes Trauma, prior surgeries, or operative scars History/presence of blood in emesis History/presence of blood in stool Severity of the pain Ecchymoses/bruising Rebound tenderness Mass or ascites
Obstetrical History
G Gravida or number of pregnancies
T Number of Term pregnancies
P Number of Preterm infants
A Number of spontaneous or inducedAbortions
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L Number of Living children
Documenting Follow-Up & Lab Reporting
Documentation of attempts to schedule follow-up visits and inform patients of laboratory results is very important.
Abdominal Pain History
Location Quality Severity Timing Aggravating factors and alleviating factors
Some causes of abdominal pain in primary care
Constipation – Patients may give a history of having small, hard pellets for stools, decreased frequency of stooling, harder stools than usual or occasionally, having loose stools, which may actually signify an impaction, where the patient actually has soft stool leaking around an impacted hard stool. Our patient has indicated that her bowel movements are alternating in consistency from loose to hard to normal. Constipation is unlikely to be her primary diagnosis. This type of stooling pattern is more often associated with irritable bowel syndrome. Irritable Bowel Syndrome (IBS) – Many patients will describe abdominal pains of varying location, associated with either soft, frequent loose stools, or constipation, or alternating stool pattern. They may also describe abdominal bloating, increased flatulence, and mucus in the stool. The symptoms of IBS are frequently worse when the patient is under stress, anxious or depressed. Symptoms of IBS can be brought on initially by a case of gastroenteritis and can be aggravated by stress, dietary changes, change in activity, and the symptoms are often unpredictable. Caffeine and dairy products can make symptoms worse. Diagnosis is based on clinical history, physical exam, and absence of alarm symptoms suggesting other pathology. The Rome IV criteria is often used to aid diagnosis of adult IBS: Recurrent abdominal pain, on average ≥ 1 day per week in past 3 months with ≥ 2 of following features:
1. related to defecation; 2. associated with change in stool frequency; 3. associated with change in stool form (appearance).
IBS should remain in your differential. Gallbladder Disease – 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. Patients with gallbladder disease may have had a recent pregnancy, had recent oral contraceptive use, or they may have the four “F’s”: be premenopausal (fertile); be overweight or obese (fat); be middle-aged (forty); and be a female. Symptoms are aggravated by the patient eating fatty foods. For our patient, we need more information about the relationship of her pain to her diet, but the location of her pain, the lack of clear association with food and the fact that she does not fit the “classic profile” (female, fat, forty, fertile) makes this diagnosis less likely. Gastritis – Mid-epigastric pain may be exaggerated by stress/emotions, diet, medications particularly non-steroidal anti- inflammatory drugs and other things that cause excess acid production. The patients frequently give a history of tobacco or alcohol use; they may use NSAID’S. Patients may state that spicy foods seem to aggravate the pain. This diagnosis should remain on your differential. Gastro-esophageal Disease (GERD) – Patients complain of chest pain, reflux, ‘heartburn’ or indigestion. It may be accompanied by an hiatal hernia. Eating hard-to-digest foods, over-eating, exercising or lying down within a few hours after eating may trigger or aggravate symptoms. More history is needed; we cannot exclude this diagnosis. Hepato-splenomegaly -This may be seen with mononucleosis which is caused by the Epstein-Barr virus. In mild cases, the patients may not be aware that they even had an infection. The importance of diagnosing this finding is the need for anticipatory guidance to reduce the risk of injury to an enlarged or inflamed spleen (through contact sports or/physical activities) or further irritation to an enlarged liver (through ingestion of alcohol or certain medications metabolized by the liver). The diagnosis of mono in this case is not likely, but be sure to rule it out more conclusively with a good physical exam. Inflammatory Bowel Disease (IBD) – Patients with IBD usually have some combination of abdominal pain, bloody diarrhea and frequent stooling. The onset of symptoms frequently occurs in the late 20’s or early 30’s. The patient may ultimately be diagnosed with either ulcerative colitis or Crohn’s Disease. Diagnosis is made through specific radiological findings on barium enema, small bowel follow- through, and by colonscopy. IBD is not a likely diagnosis. Muscular Pain or musculoskeletal pain is generally reproducible. On exam, there is usually point tenderness to palpation of the affected muscles. The pain may recur during certain activities or when the offending position is (re)assumed. We cannot exclude this diagnosis, particularly since the lower abdominal symptoms are described as achy and are aggravated by movement. The patient did give a history of having resumed an exercise program recently. Psychosomatic pain – Symptoms from this type of pain are variable and can be associated with, or aggravated by, other etiologies such as IBS or gastritis. The pains can occur anywhere throughout the abdomen. This usually presents as an atypical pain pattern, or occurs in a depressed or troubled patient, and may point towards a psychogenic cause. This is a diagnosis of exclusion; continue to consider it in your differential.
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Peptic Ulcer Disease (PUD) – While peptic ulcer disease 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). Ulcer disease can be caused by excessive use of non-steroidal anti-inflammatory medications as well. Symptoms include a gnawing, burning, boring pain in the upper abdomen, and the pain can be accompanied by bloody emesis or tarry stools. This diagnosis cannot be ruled out in our patient without further examination and testing. Stress – Symptoms are increased when the patient is under increased stress or is involved in other negative interactions. The patient may present with a whole constellation of other stress-related symptoms such as headache, depression, anxiety, appetite changes and sleep disorders. Stress can also aggravate other conditions such as irritable bowel syndrome. This diagnosis, similar to psychosomatic disease, is one of exclusion and cannot be ruled out at this time. Urinary Tract Infection (UTI) – Symptoms may include lower abdominal or suprapubic pain, urinary frequency, burning with urination (dysuria) which is frequently worse at the end of the urinary stream (terminal dysuria) and can involve hematuria. The onset of symptoms is frequently related to recent sexual intercourse. It is possible that this is the cause of the lower abdominal pain, but upper abdominal symptoms are not generally caused by a UTI. More history, physical exam and a urine analysis are needed to rule this out. Vaginitis – The patient’s symptoms and concerns will vary depending on the cause of the discharge. She can present with a vaginal discharge which is watery to pasty; it may be malodorous; discomfort can vary from itching to burning and there may or may not be pain with intercourse (dyspareunia) and pelvic pain. Being at risk for sexually transmissible infections widens the differential, and the use, or lack thereof, and the type of contraceptive used impacts that risk. An expanded history is needed in this case. Examination of the discharge under the microscope and cervical cultures are generally required.
Intimate Partner Violence – Screening Recommendations, Prevalence, and Complications
Screening recommendations:
The American College of Obstetrics and Gynecology suggests screening all patients who come to them: family planning patients, all ob-gyn patients, and all prenatal patients, at first visit, at each trimester, and at the post-partum visit. It may help to preface asking such questions with a statement such as: “Because domestic violence is so common, I ask all of my patients about this …” The USPSTF recommends that clinicians screen women of childbearing age for intimate partner violence, such as domestic violence, and provide or refer women who screen positive to intervention services. (Level of Evidence: B) This is routinely done at annual exams or when red flags are present. Here is a good resource regarding screening for intimate partner violence.
Prevalence:
It is important to be aware of domestic violence when addressing our patients as approximately 25% of women in the US report being victimized by an intimate partner at some point in their lifetime. While the majority of intimate partner violence (IPV) victims are women, IPV victims are both male and female, occur in both heterosexual and same sex relationships and cross all socioeconomic, age and ethnic divides. Complications:
In addition to the trauma incurred, the rates of chronic disease, including heart disease, diabetes, depression and suicide are significantly higher in victims as well as in adults who were victimized as children as a result of direct abuse and exposure to domestic violence.
Red Flags for Intimate Partner Violence
Women who were victimized by their intimate partner are more likely to experience:
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
Red flags for intimate partner violence include:
Delay in seeking medical care Non-compliance with treatment plan Partner insisting on staying close and answering questions directed to patient Hesitancy or not answering questions or inconsistent or incorrect answers given to questions Shyness or reticence in answering questions
Facilitating Discussion About Domestic Violence
There are several non-judgmental ways to ask about intimate partner violence. Examples include: “Do you feel safe at home?”
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“Because violence is so common, and there are so many forms of violence, I am asking all my patients about it. Is anyone now or has anyone in the past hurt you physically or sexually. Is anyone threatening you?” “All couples disagree at sometime. What happens when you disagree/fight/argue?” “Does your partner ever force you to do things you do not want to do or keep you from doing things you want to do?” “How do you handle money issues in your relationship?” “I often see the type of symptoms that you have in people who are being hurt at home or in a relationship. Is this happening to you?”
There are lots of things you can do to facilitate discussion about domestic violence.
Ask screening questions
Many physicians’ offices will ask a screening question of all patients during the triage process. Asking the patient, “Do you feel safe at home?” follows the vital signs and question about whether or not the patient is having any pain. This allows the patient to share information about feeling unsafe at home, in their neighborhood, where they live or shop, to feeling threatened or being actually abused by someone. This question is appropriate for any age, gender, or socioeconomic class. It may take several visits for the patient to feel comfortable enough with the provider to discuss such a sensitive issue.
Create a safe setting
Hang posters on the walls and place brochures about safety, particularly in private areas like bathrooms and exam rooms. These should also contain information addressing cultural differences and acknowledging varied relationships and backgrounds.
Interview the patient alone
Never interview with the suspected perpetrator present. In order to have the partner leave the room, you can cite protocols such as, “I always do this part of the exam just with the patient. You can join us again when we are done.” Or, “I begin the visit with the patient alone, if you have questions after, we can meet together.”
If the partner insists, then attempt to separate the two by taking the patient to obtain a urine sample or another test outside of the exam room. Infants and toddlers up to the age of three can stay with the parent, but it is recommended if they are older than three years old, that you meet with the patient alone.
Ensure confidentiality
Update and review HIPPA forms and make sure staff are aware of how to use them. Be sure to tell the patient that anything discussed in the room will not be shared with anyone not directly involved with their care including their partner/family members.
Direct assessment
Interviewing can begin with indirect questions such as, “Tell me about your relationship,” but should include a direct assessment of safety including questions regarding weapons in the house and danger or possible harm to the children
Know your local laws
All states require reporting of child abuse and some require reporting of intimate partner violence. Be open with your patient about your legal constraints.
Facilitate impartiality
Consider using a telephone service for interpretation if an appropriate professional interpreter is not present in the office.
Listen non- judgmentally Validate the patient’s concerns and the fact that abuse is not the fault of the victim.
Common Symptoms of Exposure to Domestic Violence in Children and Adolescents
Obvious physical signs of physical or sexual abuse Behavioral or emotional problems, such as increased aggression, increased fear or anxiety, difficulty sleeping or eating, or other signs of emotional distress Chronic somatic concerns
30% to 60% of perpetrators of intimate partner violence also abuse children in the household.
Intimate Partner Violence Safety Assessment
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
Increasing Severity of Intimate Partner Violence
1. Verbal abuse, insults, yelling 2. Throwing things, punching wall 3. Pushing victim or throwing things at victim
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4. Slapping 5. Kicking, biting 6. Hitting with closed fist 7. Attempting strangulation 8. Beating up; punching with repeated blows 9. Threatening with weapon
10. Assault with weapon
Escalating Cycle of Intimate Partner Violence
Intimate partner violence is a pattern of increasing episodes of violence in which one partner exerts control over another through intimidation, physical and/or emotional violence, and threats. It is common for there to be a tension-building phase, a crisis phase when overt violence is likely to occur followed by a calmer phase when the abuser might ask for forgiveness and even be affectionate. Unfortunately, in most cases, the cycle begins again and often the violence is increasingly severe.
Documenting a Case of Suspected Domestic Violence
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. Document abuse history as reported by patient in the subjective. The subjective section is meant to document the patient’s experience and verification is not applicable. Include any laboratory and radiology tests ordered with results to maintain a complete record for the patient. Document results of health and safety assessments and plans for follow-up as well as referrals and materials given to the patient. Document recommendations for support. If the patient was referred for a post-rape exam, document the referral site. Maintain strict confidentiality and safeguard the chart rather than limit the contents for best care practices.
Clinical Skills
Adequately Addressing Your Patient’s Needs Within Time Constraints
It is a common scenario to see a patient that is scheduled for an acute visit, but the situation requires more time to be adequately addressed. Prioritize the most acute or high risk issues raised during this visit and focus on these, and then emphasize the importance of follow-up and schedule a follow up visit as soon as possible.
Management
The Role of the Health Care Provider in the Care of a Victim of Domestic Violence
Acknowledge the abuse and health implications
It is important to acknowledge the abuse, recognize the health implications, and share this with your patient.
Support your patient’s decisions
While you may not always agree with the decisions your patient makes to stay or escape, it is important that you support their decisions. They have a greater understanding of the complexity of the problem, and have more information on which to base their actions.
Address safety issues
Address the level of risk and safety issues for your patient. Provide information for them to go to a safe haven if needed. As lack of telephone or computer (or monitoring of their use) often make it unsafe or impossible for victims to contact domestic violence resources from home, it is important not only to give contact information to the patient, but also to offer a means for them to contact services while in your office.
Practice cultural sensitivity
Cultural differences can give the appearance of abuse, be accepting of practices some might consider abusive and can inhibit the ability to interview or support a victim. Practicing sensitivity in caring for patients from different backgrounds is key to a supportive patient/physician relationship.
Consider impact of abuse on children and
When children or other vulnerable persons who are less able to make decisions on their own behalf are in the home, consideration must be given to the impact of the abuse on them physically and mentally as well as their
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other vulnerable parties
safety. Even in states where reporting abuse towards a domestic partner is not mandated, the impact or abuse on a child or other vulnerable person may be and will supersede the desires of the victim to not alert social services.
It is not possible for a clinician to solve the problem of domestic violence for an individual. Statistically, the most dangerous time for a victim is when they escape an abusive relationship. While it is hard to accept, sometimes it may be safer for a victim to stay with the perpetrator. Physicians are not in a position to stop the abuse. You can make recommendations in terms of decreasing the victim’s level of risk by of providing resources to the patient, limiting access to weapons, and developing an escape plan with a victim’s advocate. Safety planning takes time and expertise. While some physicians will take the time to be trained to be effective at this, it is probably best to utilize experts who are associated with domestic violence agencies if available or to train a staff member to serve this role. Reporting
The laws, in terms of reporting, differ from state to state, so you need to know what the laws are where you are working. Whenever a child is abused, either intentionally or unintentionally, as a result of intimate partner violence, state law requires health care providers to report this abuse to child protection services. Mandated reporters would also report any high-risk situation of intimate partner violence in which children are at risk. However, state laws are less clear about whether exposure to domestic violence in the absence of injury or serious risk of injury to the child would require a report to children’s protective services. In some states, stringent rules/laws require mandated reporters to notify child protection services whenever a child is in the home and has been exposed to a parent’s abuse, whether or not the child has been directly abused. Proponents of this definition point to the ample documentation of the overlap between adult intimate partner violence and child abuse and the adverse psychological effects on children who witness intimate partner violence. Opponents of this policy believe it penalizes women for abuse that they have no control over and may discourage women from seeking help. It also could elevate the level of risk for the victim. In other states, a child’s exposure to intimate partner violence does not automatically require a mandatory child protection report. The provider has wider discretion to assess whether a child has been directly involved and what other factors may exist to put the child at risk. In these states, a provider would take into account the existence of direct injury to a child, the potential danger of the situation, and the capacity of the mother to keep her children safe in deciding whether to notify Child Protective Services (CPS). The rules for victims who are adults and are not disabled vary dramatically from state to state from mandatory reporting for evidence of abuse to reporting only if the victim asks the clinician to do so. Contact your local Domestic Violence helpline and ask what the rules are for the community in which you work. You can find out about your local resources by calling the National DV Hotline at (800) 799-SAFE, TTY (800) 787-3224.
Studies
Recommended Studies for Evaluation of Abdominal Pain
Pap smear – thin prep Recommended in the setting of previous abnormal results.
KOH/Saline wet prep
This is a quick test which should be done as it could indicate inflammation (white blood cells) or diagnose trichomonas, bacterial vaginosis, or yeast vaginitis.
Chlamydia / gonorrhea DNA probe
Chlamydia and gonorrhea can present with a yellow discharge, abdominal pain, and dyspareunia. This is the preferred method for diagnosis of chlamydia and gonorrhea because both can be performed using the same sample and the sample can be endocervical, urethral, vaginal, or urine.
Urine dipstick A urine dipstick will be helpful to rule out a urinary tract infection (UTI).
Urine pregnancy test
This test should be performed on any patient who is able to be pregnant.
RPR RPR should be done as part of the STI screen to rule out syphilis.
HIV HIV should be done as part of the STI screen.
HPV Consider ordering a Reflex HPV. Reflex refers to the fact that an abnormal Pap will automatically be tested forHPV. If the Pap is normal, the HPV testing will not be done.
Pelvic ultrasound
Pelvic exam, urine pregnancy test, and STI testing will guide you in terms of the need for an ultrasound to evaluate a possible pelvic mass, the size of uterus and ovaries, to confirm the location of a pregnancy, or to rule out an inflammatory or infectious process.
Colposcopy is not indicated until the results of the Pap are back. If the Pap is abnormal, and/or if HPV is positive, a © 2020 Aquifer 6/9 https://www.coursehero.com/file/65700917/case-summary-FamilyMedicine20-28-ypdf/
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Colposcopy colposcopy may be indicated. Follow the ASCCP guidelines for follow up of abnormal PAP
Gonorrhea culture
While this is a good test for gonorrhea, a separate test needs to be done on vaginal or urine samples. However, this is still the preferred method for sexual assault tests, for tests of cure, and for oral and rectal specimen.
HCG beta sub This is generally not indicated because of the sensitivity of the urine pregnancy test. If the results of the urinepregnancy test were inconclusive, a blood test such as HCG Beta Sub would be needed.
Clinical Reasoning
Severe / Life-Threatening Causes of Abdominal Pain
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.
Hepatitis
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.
Ovarian pathology
Patients with ovarian problems generally have lower abdominal or pelvic pain. Pain from ovarian torsion or ruptured cyst or ectopic pregnancy may be very severe. Patients often present to the emergency department due to the pain, and this is appropriate since imaging is usually necessary to determine the exact cause of the pain. In several cases, the pain from ovarian problems may persis for several weeks, and it is often aggravated by intercourse or strenuous activity.
Pancreatitis
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.
Pelvic inflammatory disease
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.
Normal pregnancy
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.
Ectopic pregnancy
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 (always get a pregnanacy test if the patient has a uterus) 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, the types of contraception used currently and used in the past /ever used, history of any vaginal or pelvic infections, and history of previous ectopic or normal pregnancies.
Trauma 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. Consider taking a photograph of any injuries and bruises if there is a way to appropriatey attach them to the patient’s medical record, and if the patient gives consent.
Differential of Abdominal Pain in Sexually Active Woman Without Birth Control
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Most Likely / Most Important Diagnoses
Appendicitis
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.
Pelvic inflammatory disease (PID)
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.
Normal pregnancy
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.
Ectopic pregnancy
Ectopic pregnancy can present with a myriad of symptoms and findings ranging from normal to severe pain and abnormal findings on pelvic exam.
Trauma
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.
Gastritis
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.
Irritable bowel syndrome
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 generally a diagnosis of exclusion.
Symptoms of IBS can be brought on initially by a case of gastroenteritis and can be aggravated by stress, anxiety, and depression, dietary changes or change in activity, and are often unpredictable.
Vaginitis
Symptoms and concerns 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. The use of certain types of contraceptives can impact the risk of STDs, so an expanded history is needed in this case.
Examination of the discharge under the microscope and cervical cultures are generally needed.
Less Likely Diagnoses
Gallbladder disease
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.
There is increased risk if the patient has 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.
Patients with inflammatory bowel disease (IBD) have abdominal pain, bloody diarrhea and frequent stooling.
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Inflammatory bowel disease
The onset frequently occurs when the patient is in their late 20s to early 30s.
IBD is diagnosed by small bowel endoscopy, colonoscopy, flexible sigmoidoscopy, or barium enema.
Peptic ulcer disease
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.
Urinary tract infection
Urinary tract infection (UTI) symptoms may include lower abdominal pain, burning with urination (dysuria) that is worse at end of urinary stream (terminal dysuria), and can involve hematuria.
The onset of symptoms is frequently related to recent sexual intercourse.
References
(Table of available contraceptives and efficacy). Accessed May 2017.
American Society for Colposcopy and Cervical Pathology Updated Consensus Guidelines for Managing Abnormal Cervical Cancer Screening Tests and Cancer Precursors. Accessed May 1, 2017.
Cartwright SL, Knudson MP. Evaluation of acute abdominal pain in adults. Am Fam Physician. 2008 Apr 1;77(7):971-978.
Connor VF. Essure: a review six years later. J Minim Invasive Gynecol. May 1, 2009;16(3):282-90.
Edelson, J.L. (1999). “The Overlap Between Child Maltreatment and Woman Battering.” Violence Against Women. 1999;5:134-154.
Futures Without Violence (formerly Family Violence Prevention Fund) fact sheets. https://www.futureswithoutviolence.org/resources- events/get-the-facts. Accessed May 1, 2017.
Futures Without Violence (formerly The Family Violence Prevention Fund). First Printing: September, 2002. Updated: February, 2004. Accessed May 1, 2017.
Hatcher RA et al. Contraceptive Technology 19th edition, Ardent Media, 2007. http://www.contraceptivetechnology.org/table.html. Accessed May 1, 2017.
How to obtain, prepare and read a wet mount or wet prep:
Institute for Clinical Systems Improvement (ICSI). Initial management of abnormal cervical cytology (Pap smear) and HPV testing. Algorithm. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); Oct 2008;32:63. http://guideline.gov/algorithm/6755/NGC-6755_1.html
Katz VL et al, Infections of the Upper Genital Tract: Endometritis, Acute and Chronic Salpingitis In: Comprehensive Gynecology, 5th edition. Philadelphia, PA: Mosby; 2007.
National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings. Produced by The Family Violence Prevention Fund, 383 Rhode Island Street, Suite 304, San Francisco, CA 94103-5133. (415) 252-8900. TTY (800) 595-4889. First Printing: September, 2002. Updated: February, 2004.
National Women’s Health Information Center US Department of Health and Human Services Office on Women’s Health. Table of Contraceptives. https://www.womenshealth.gov/files/assets/docs/fact-sheets/birth-control-methods.pdf. Accessed May 1, 2017.
Planned Parenthood Interactive website. http://www.plannedparenthood.org/health-topics/birth-control-4211.htm. Accessed May 1, 2017.
Silverman JG, Decker MR, Reed E, Raj A. Intimate partner violence victimization prior to and during pregnancy among women residing in 26 U.S. states: associations with maternal and neonatal health. Am J Obstet Gynecol. 2006 Jul;195(1):140-8. Epub 2006 Apr 21.
The Facts on Domestic, Dating and Sexual Violence. Accessed May 1, 2017.
The Facts on Women, Children and Gun Violence. Accessed May 1, 2017.
The Health Care Costs of Domestic and Sexual Violence. Accessed May 1, 2017.
Trigg BG, Kerndt PR, Aynalem G. Sexually Transmitted Infections and Pelvic Inflammatory Disease in Women. Medical Clinics of North America. September 2008;92,(5):1083-1113.
Vermont State Medical Society. Clinical Guidelines: Improving the Health Care Response to Domestic Violence in Vermont: Resource Page for Health Care Practitioners and Administrators
Your Birth Control Choices. Reproductive Health Access Project. http://www.reproductiveaccess.org/wp- content/uploads/2014/06/contra_choices.pdf. Accessed March 16, 2018.
http://www.brooksidepress.org/Products/Military_OBGYN/Textbook/Discharge/WetMount.htm. Accessed May 1, 2017.
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