RLQ Pain

History of Present Illness: A woman in her 20’s presents to the ER for 2 days of RLQ pain with some radiation to her low back associated with nausea but no fever, diarrhea, dysuria, discharge or other complaints.

Vital Signs & Physical Exam: Vital signs are normal

Physical exam is otherwise normal except for slight RLQ tenderness

Initial Diagnostic Testing:

  • CBC: normal except but CRP elevated at 16
  • Chem-7: normal except
  • UA: shows shows 100 WBC and 30 squammes, few bacteria
  • Imaging: US shows dominant R ovarian follicle/cyst 1.6 cm in size and small, likely physiologic, free fluid.  CT for appendicitis was negative

What is the most likely diagnosis?

  • A) Ovarian cyst
  • B) Mittleshmertz
  • C) PID
  • D) Ovarian torsion

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ANSWER:

  • A) Ovarian cyst – usually painless if simple and <2.5cm
  • B) Mittleshmerz – a diagnosis of exclusion and would need to know where she was in her cycle.  Should be midcycle and rarely lasts more than a day
  • C) PID – common and frequently presents with mild and/or atypical symptoms along with an unimpressive exam and CBC.
  • D) Ovarian torsion – unlikely given size of follicle/cyst and clinical presentation

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CASE CONCLUSION: cath UA was normal, pelvic exam had mild milky discharge and slight CMT, chlamydia was positive

CASE LESSONS: Free fluid can be seen at any point in menstrual cycle but is most common in the 5 days prior to onset of menses.  The fluid is thought to be due to increase capillary permeability from estrogen spiking rather than from ovulation itself