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RLQ Pain*4

History:

A 32-year-old female with no significant PMH presents to the ED with 2 days of gradually worsening suprapubic and RLQ pain that radiates to the back and is associated with 5 episodes of non-bloody vomiting but no fever, dysuria, diarrhea or discharge.  She denies other complaints.

Exam:

Vital signs are all normal.  Abdomen: Soft, there is diffuse lower abdominal tenderness, worse on the right and guarding as well as right CVA tenderness

Initial Concern(s):

  • PID
  • ovarian cyst
  • pyelonephritis
  • kidney stone
  • appendicitis

Testing:

  • WBC = 11, other blood work negative
  • UA small blood, otherwise negative.
  • A pelvic ultrasounds a 3.5 cm simple right ovarian cyst with good flow and no free fluid.
  • A CT scan is shown below

ct-ovarian-cyst

 

Questions:

  1. What does the CT show?
  2. What should be done next?

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ANSWERS:

  • What does the CT show? The arrow is pointing to the uterus.  To the right and anterior there is a 3.5 cm simple right ovarian cyst.
  • What should be done next?  KEEP LOOKING.  The CT was done to make certain there was no concomitant appendicitis as ovarian cysts don’t usually cause vomiting in the absence of torsion.   A higher slice of the CT is reproduced below.  What does it show?

 

ct-appy

This cut of the CT shows acute appendicitis.  Remember that gallstones and ovarian cysts can be incidental findings (AKA Incidentalomas, Red Herrings).  So can a dirty urine.  If something doesn’t fit always ask yourself, “Should I keep looking?”  She was taken to the OR and had a successful appendectomy of an unruptured appendix.

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OVARIAN CYST from QUICK ESSENTIALS: Emergency Medicine 1-minute consult pocketbook

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