[PedOncoDoc]

Originally Posted by Sdiver

Okay, this one might be just a bit too easy, but let's see how it unfolds. I'll set this up to be as dynamic as possible and answer all questions as they come up.

I initially set this up as the patient being deaf and can only communicate through American Sign Language (ASL), but obviously, we can't do that here, but do kind of keep it in the back of your mind that the patient is deaf and you do have a language "barrier" to work through.

You respond on an unknown medical to a upper middle class neighborhood in an affluent suburb. Your patient is a 38 y/o female c/o abdominal pain. U/A find Pt. sitting in chair in living room, holding her stomach, rocking back and forth in obvious pain/discomfort.

Initial exam reveals Pt/ c/o pain in RLQ.
Pain scale 10 out of 10. Pain radiates to other three quadrants only upon palp.
RLQ is hot to the touch, with rigidity and guarding. Describes it as a “Sharp, Stabbing Pain.” Pain is more severe towards midline than lateral.

Pt. states, she didn't feel well last night. Had some slight discomfort before going to bed, but awoke this morning and felt okay. States that this pain started a few hours ago, dull at first then came on “Like a lightning bolt”.

Vitals:
B/P 102/64
HR 126 (weak)
RR 28, non-labored
SPO2 97 RA
BGL 112
Slight Nausea but has not vomited.

Had breakfast this morning; Coffee, toast and 1/2 grapefruit.

Past med Hx: Right femur Fx when she was 19 y/o

Allergies: Morphine, Codeine, Bees, Peanuts

Meds: multi-vitamins, currently on Clomid, was recently on Follistim (but discontinued due to adverse side effects).


What is your initial Dx?
What is your treatment?
What special considerations will you have?

*Ask questions and I'll answer as best I can. SD

I'm worried about ovarian torsion first and foremost, also consider ruptured ovarian cyst or ectopic/tubal pregnancy. I also cannot rule out appendicitis or other intestinal issue (undiagnosed malrotation with volvulus, etc), although an obstruction is less likely given the lack of vomiting, especially after having breakfast.

Given she is on reproductive assistance medications, one must presume she is pregnant and should select medications and work up (imaging) appropriately.