An intimate moment, a case study

Sometimes we get caught up in the details and forget the basics.  This case is relatively straight forward and it involves abdominal pain.  Since abdominal pain accounts for up to 10% of ED visits, it’s crucial to have a broad differential and not forget the basic approach.  So here we go…

ouch

(not my actual patient…)

(All identifying information has been removed and details have been changed)

Triage Note:

  • CC: “Patient with suprapubic pain that started last night after sexual intercourse”
  • Vitals: Temp: 98.7 Pulse: 99 Resp: 19 BP: 165/82 SpO2: 100% RA
  • EMS Treatment prior to arrival: 4mg Zofran, 100mcg Fentanyl

History of Present Illness:

32 year-old female presents to the ED via EMS complaining of abdominal pain.  EMS was called to transport the patient from her PCP’s office.  Paramedics report she was doubled over in pain, nauseous and tearful in the exam room upon their arrival.  She received 100mcg of Fentanyl and 4mg of Zofran en route to the hospital with some relief.  Last night around midnight, immediately following intercourse, she had a sudden onset of lower abdominal pain she described as a “dull aching.”  Over the course of the night the pain began to gradually worsen and become more generalized and kept her awake most of the night.  Now the pain is very severe and feels “sharp” with radiation to the back.  Movement causes severe pain that “takes my breath away.”  Pain is worse when she lies flat on her back, and her abdomen feels “bloated.”

Review of Systems:

  • Constitutional: No fevers, chills
  • CV: No Chest Pain
  • Resp: Reports that waves of pain “take her breath away,” no shortness of breath, no cough
  • GI: Nausea, improved with Zofran. No vomiting, diarrhea, constipation or melena
  • GU: No vaginal pain or discharge, no abnormal vaginal bleeding, no urinary symptoms

Medical History:

  • Medical History: G2 P2
  • Surgical History: c-section x2 (low transverse)
  • Medications: IUD
  • Allergies: None

Physical Exam:

  • Vitals: T: 97.8  P:96  BP:103/64  RR: 18
  • Gen: A+Ox3, sitting upright in bed holding abdomen, in obvious pain
  • CV: RRR, no MRG, symmetric pulses in all extremities
  • Resp: Lungs CTAB, no respiratory distress
  • Abd: Protuberent abdomen, soft, not tympanic. Moderate diffuse TTP, no rebound or guarding, no palpable organomegaly or masses.
  • GU/GI: Unable to perform speculum exam as patient could not tolerate positioning due to pain. Bimanual exam with mild uterine tenderness and mild left adenexal tenderness. No blood or discharge noted. Rectal exam normal, heme negative.
  • Back: Normal appearance, no CVA tenderness
  • Ext: Atraumatic, no cyanosis or edema
  • Otherwise unremarkable exam

Lab Data:

  • Urine Preg: Negative
  • UA: Normal
  • CBC: WBC: 13.0  Hb: 11.5  PLT: 304
  • CMP: Normal
  • Lipase: Normal

Moving forward…

We were unable to perform a bedside trans-vaginal ultrasound due to her discomfort (she was unable to lie flat).  Trans-abdominal ultrasound was unremarkable.  We decided to move forward with a CT of the abdomen and pelvis…

Before I give away the diagnosis, let’s take a step back and summarize:

  • 32 y/o female, negative pregnancy test, suprapubic pain immediately following intercourse, now has peritoneal signs, hemodynamically stable

This helpful image from Rosen’s is good for localizing abdominal pain.  Our patient had diffuse pain but could also localize it to the lower quadrants.  Obviously female-specific pathology is important here, but don’t forget about gender-neutral pathology such as appendicitis, diverticulitis, ureteral calculi, pancreatitis, biliary disease, etc.

abd pain

Back to our patient…

History is very important!  This lady initially had suprapubic pain, immediately after intercourse, that became diffuse over a short period of time.  It was worse with movement, and took her breath away.

Exam is very important!  She was doubled over in pain, had a protuberant abdomen, and couldn’t lie flat on the bed.

So we finally got the CT.  You might expect to see something causing peritoneal signs.  And the diagnosis was…

Large, ruptured, functional left ovarian cyst with hemorrhagic ascites.

Ruptured Ovarian Cyst

Ruptured ovarian cysts are very common and symptoms may vary widely.  Rarely, intraperitoneal hemorrhage results.  They usually occur following strenuous activity, and the most common time is mid-cycle.  They can be associated with nausea/vomiting, vaginal bleeding, weakness, shoulder tenderness (due to diaphragmatic tickling), and ultimately (and rarely) circulatory collapse.

The most important thing in the workup is to rule out ectopic pregnancy.  The presentation can be a close mimic to ectopic, so get that UPT cooking as soon as you can.  And get the ultrasound in there!  Unfortunately we couldn’t with our patient, but it may have spared her the radiation of a CT.

One of the main points I took away from this case was conservative management.  The management for ruptured ovarian cysts really involves three components:

  1. rule out ectopic
  2. hemodynamic stability
  3. pain control

If there is no ectopic, they are stable, and their pain is controlled, they can go home.

So in summary, this is a pretty basic case and a common presentation.  As I move forward in my education, it’s tempting to focus on the new, sexy details of EM and skip over the basics.  Hopefully this will help.  Please let us know if you have any other pearls for dealing with ruptured ovarian cysts or female abdominal pain in general.  Thanks.

References:

Rosen’s Emergency Medicine – Concepts and Clinical Practice, 8th edition

Tintinalli’s Emergency Medicine Manual, 7th edition

Emedicine.Medscape.com, Ovarian Cyst Rupture

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