Intern Report Case 1.1

A 34-year-old woman presents to the Emergency Department complaining of pain in her right side.  The pain had a gradual onset over the last couple of days.  She first noticed the pain while sitting and watching television. There is nothing that exacerbates the pain.  Pain medication does not provide relief.  Currently the pain is 10/10 and radiates from her right flank to her back and into her pelvis.  She describes the pain as stabbing.  She feels nauseated and had an episode of emesis today.  She denies constipation, diarrhea, fever, chills, chest pain, and shortness of breath.  The patient was evaluated in the ED yesterday for the same pain and was diagnosed with a sexually transmitted disease (STD).  She was started on an antibiotic that she doesn’t have with her.  She was instructed to return to the ED if her pain worsened and was uncontrolled with medication at home.  She returns to the ED with worsening pain.

Physical Exam

VS: BP138/88 mm Hg    HR70 beats per minute  RR 18 breaths per minute  Temp 36.5°C, and oxygen saturation of 99% on room air.

General appearance: writhing around on the stretcher, holding her right side, periodically tearful

Head: atraumatic

Eyes: EOMI, PERRLA, anicteric, no pallor

Mouth: mucosa moist, normal tonsils without erythema, vesicles, or exudates

Neck: supple, no lymphadenopathy, no JVD, no goiter

Respiratory: CTA b/l, no wheezes, rales, or rhonchi

Cardiovascular: no murmurs, rubs, or gallops, 2+ pulses in all extremities

Abdomen: obese, soft, tender in the right upper and lower quadrants, no rebound or guarding, mild CVA tenderness on the right, normal bowel sounds

Pelvic: whitish foul-smelling discharge, os is closed, friable cervix with minimal bleeding when swab taken, no cervical motion tenderness

Extremities: no cyanosis, clubbing, or edema

Musculoskeletal: full range of motion throughout

Skin: warm and dry, no rashes

Neurological: A & O x3, CN II-XII intact, normal sensation and strength throughout
Lab Results

CBC and electrolytes within normal limits

U/A: 2-5 trichomonas, trace leukocyte esterase, no nitrites, no blood, 2+ bacteria

Diagnostic Studies

CT Abdomen-Pelvis w/o contrast: 2 cm hypodense mass in left adrenal gland, 4.4 cm cyst in left adnexa, 6.1 cm cyst in right adnexa, gallbladder, kidneys, and appendix all normal in appearance
Pelvic U/S: left ovary is 5x4x3 cm, right ovary is 7x5x5cm containing a 3x4x4cm hypoechoic lesion with no arterial wave form, fluid in the right cul-de-sac


1. What is the most common type of adnexal mass in the reproductive years?
A.    fibroid
B.    tubo-ovarian abscess
C.    carcinoma
D.    physiologic cyst
E.    endometrioma

2. What is the first step in management of a woman with pelvic pain and unstable vital signs?
A.    consult to Ob/Gyn
B.    send to OR
C.    wide-bore IV access and volume resuscitation
D.    CBC and electrolytes
E.    Pelvic ultrasound

3. What is the gold standard for diagnosis of acute pelvic pathology?
A.    ultrasound
B.    laparoscopy
C.    laboratory tests
D.    CT with contrast
E.    CT without contrast

Please submit your answers to the questions in the “leave a reply” box or click on the “comments” link.  Your submission will not immediately post.  Answers with a case discussion will post on Friday.  If you have any difficulty, please contact the site administrator at Thank you for participating in Receiving’s: Intern Report.

2 Responses

  1. dca

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