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Fever and RLQ Pain*

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History of Present Illness:

A 27-year-old female presents to the ED for gradually worsening generalized abdominal pain today. It started in the right lower quadrant but now is all over her lower abdomen. She does have a chronic right lower quadrant pain but this is very different. She also states the pain is worse with walking and she has had a subjective fever. She denies any vomiting or abnormal discharge. She states she has had a kidney stone in the past and the pain feels about the same.  She denies any vomiting, diarrhea, dysuria or new sexual partners.  She has lived with her boyfriend for 4 years.

Vital Signs & Physical Exam:

Vital signs are normal.  Physical exam is normal except for mild lower abdominal tenderness bilaterally

Initial Differential Diagnosis:

  • Kidney stone
  • Appendicitis
  • Ovarian cyst
  • PID

Initial Diagnostic Testing:

  • CBC shows a WBC of 19,000.
  • BMP normal except for a sodium of 132.
  • UA is negative except for 25 RBCs
  • Abdominal CT and pelvic ultrasound were both normal

QUESTIONS:

  1. What should you do next?  
  2. Want a 1-minute consult/tutorial on this case? 
  3. Want to know what happened with this patient?

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ANSWERS:

  1. What should you do next?  A pelvic exam.  She had mild cervical motion tenderness (CMT).  Gynecology was consulted for admission
  2. Want a 1-minute consult/tutorial on this case?  See yellow area from sample page below.
  3. Want to know what happened with this patient?  See case conclusion below tutorial page.

1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

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CASE CONCLUSION: The gynecology resident told me that there was no CMT on exam and recommend discharge home.  She was called back when the temperature spiked to 103.4.  The team recommend admitting to medicine for a non-gynecologic cause of fever and abdominal pain.  Additional labs: ESR normal at 5, CRP extremely elevated at 85.  Two days later the GC came back negative but chlamydia came back positive.  She is transferred to the gynecology service, treated for PID and does well.

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