NON-ENGLISH SPEAKING FEMALE PATIENT WITH LEFT LOWER QUADRANT ABDOMINAL PAIN Bihter Korbeci, PGY3 – St. Joseph’s Health

History of Presenting Illness

The rest of her history     

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PMH – Viral pharyngitis PSH – none Allergies – NKDA Medications – none Social history – negative x3, Sexually active with her husband only. FMH – Parents and siblings generally healthy

Physical Exam Vitals: BP 133/84 | Pulse 84 | Temp(Src) 98.1 °F (Oral) | Resp 18 | Wt 61.236 kg (135 lb) | LMP 04/30/2015 

Abdominal: Soft. Bowel sounds are normal. She exhibits no distension. There is tenderness. There is no guarding. LLQ tenderness, non radiating. Genitourinary: Vagina normal. No vaginal discharge found. Bimanual exam exam showed cervical motion tenderness, positive adnexal tenderness bilaterally, no adnexa fullness/mass

Discussion – Abdominal pain in Healthy young Female

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Does Pelvic Exam in the Emergency Department add useful information to patient’s management? Which imaging modality to choose to further investigate pelvic pain?

Brown et al. 2011  

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Prospective Cohort Study 320 patients selected from list of patients where attending physician determined need for pelvic exam. Provider was asked reason for pelvic exam and prediction of result. After pelvic exam, provider was asked of actual findings on exam. Laboratory and radiographic tests also collected to correlate with predicted and actual findings of pelvic exam.

Brown et al. 2011 

Limitations – Providers were not asked of their management prior and after pelvic exam. They were not asked how particular unexpected findings changed their management. Patients needing cervical cultures were excluded from study.

Williamson and Aldeen 2010 

American College of Emergency Physician current recommendation regarding management of pelvic inflammatory disease  Reviewed

current research regarding diagnosing and treatment modalities of pelvic inflammatory disease  Despite nonspecific nature of the presenting signs and symptoms of PID, they see pelvic examination as “the most useful component of the physical exam to aid in diagnosis”.

Does Pelvic Exam in the Emergency Department add useful information? 

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Johnson et al (2013) and Brown et al (2011) performed a study to determine if vaginal examination improves diagnostic accuracy in women who presented to the Emergency Department. Johnson et al (2013) looked at first trimester pregnant females and Brown et al (2011) looked at any woman who required a pelvic exam. Providers would predict pelvic exam findings and diagnosis  Ultimately, there was no significant predictive factor added by performing a pelvic exam. Isoardi (2009) performed a medline search review of 43 articles looking at routine use of pelvic exam in the Emergency Department.  Pelvic exam did not add to diagnosis more than checking ultrasound and a Bhcg. Williamson and Aldeen (2010) looked at evaluation and management of PID in the emergency room patients. Their recommendations are on American College of Emergency Physicians.  ACEP recommends performing pelvic exams as “the most useful component of the physical exam to aid in diagnosis”.

Does Pelvic Exam in the Emergency Department add useful information?

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Yes/No. Ultimate answer depends on differential diagnosis.

CT scan vs U/S imaging Modalities for Investigation of Pelvic Pain American College of Radiology Appropriateness Criteria 

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Based on expert panel on women’s imaging and literature review comparing risks vs benefits of each imaging modality. Recommendation provided based on clinical condition and variants.

CT scan vs U/S imaging Modalities for Investigation of Pelvic Pain American College of Radiology Appropriateness Criteria 1 – Acute pelvic pain in reproductive age group presents diagnostic challenges. 2 – The choice of the correct imaging test depends on the results of a careful clinical evaluation in order to narrow the differential diagnosis. 3 – The first step is to measure Bhcg 4 – Pregnant patients with acute signs of infection and suspected gynecological etiology for pain  Pelvic u/s with adnexal Doppler would be initial modality to assess the etiology  If u/s is inconclusive then MRI would be the next modality of choice. 5 – Non-pregnant patients with suspected gynecologic etiology for pain, u/s is still the best imaging modality  contrast enhanced MRI Contrast enhanced CT scan 6 – Non pregnant with non-gynecological origin of pain  contrast-enhanced CT scan is the modality of choice.

Returning to our patient…

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What is your differential and what would you like to order?

Differential and Work-Up 

My differential at the time I saw patient Ovarian torsion  STDs/PID  Ectopic pregnancy  TOA  GI (IBD, IBS)  GU (UTI, kidney stone) 

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Labs ordered Urine Dipstick, Urine Pregnancy test  CBC, CMP  U/S pelvis/transvaginal  GC/CH, Vaginitis Direct 

Lab results   

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Urine dipstick – within normal limit Urine pregnancy test - negative 139/4.1/102/28/6/0.711/33.3