Medical Challenge | Abdominal Pain

Posted on November 6, 2011

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This is the interesting case I promised you last week – I think it allows for several great teaching points.  Take your time, and share this one with your friends. -Jim

A 33 year old woman presents to the emergency department complaining of severe abdominal pain.  When you go to examine the patient, you notice she is uncomfortable & diaphoretic – one of your clumsy medical students walks into the corner of her bed and she grimaces in pain.  When you ask, she tells you the pain began not long after she had sex with her partner several days ago.  At home, she has been running a temperature of 101F for 4 days and has not been able to eat or drink much.  She does report several episodes of nausea and vomiting, and has not had a bowel movement in 4 days (but claims this is not unusual for her), but her last BM was normal and without blood or mucus.  She denies discomfort with urination (dysuria), urinary frequency, and vaginal discharge.  She and her partner are in a monogamous relationship and do not use condoms.

Medical History:  Bipolar disorder, basal cell carcinoma (upper back), uterine fibroids with bleeding, narcotic abuse (5 years sober).

Surgical History:  appendectomy at age 20, excision of basal cell carcinoma at age 27, laparoscopic transvaginal hysterectomy7 weeks prior to admission.

Her medications include Depakote (valproic acid), Zoloft (sertraline), and an oral contraceptive.

On exam, her abdomen is exquisitely tender and she protests even when you place your stethoscope upon it momentarily – you are not able to hear any bowel sounds during this brief period.  She does not have any rashes, and her cardiovascular and pulmonary exams are unremarkable.  Her pupils are 4mm & reactive to light, her sclerae are anicteric, and cranial nerves II-XII are intact.  Her temperature is 102F, BP is 118/66, pulse is 90 bpm, and respirations are 20/min.

You gain IV access and start an infusion of 0.9% saline while you discuss the case with your team.  When you exit the patient’s room, you are informed that the patient’s chest X-ray is ready for viewing.

Click to enlarge.

What is the most likely cause of this patient’s abdominal pain?

  • A) Pyelonephritis
  • B) Metastatic cancer
  • C) Surgical wound dehiscence
  • D) Fitz-Hugh-Curtis syndrome
  • E) Gastroenteritis
  • F) Drug overdose

Please leave your answers in the comments section below.  Check back in 48 hours for the answer and explanation.  If you would like to submit a guest post or a medical case of your own, please use the contact page.

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Posted in: Medicine