Right lower quadrant pain

Abstract

Dr. Martin Lucenti: Today’s case is that of a 47-yearold woman G1P0 with the complaint of right lower quadrant (RLQ) pain. The patient had a history of uterine fibroids and ovarian cysts. The pain was described as crampy and nonradiating, and was similar in nature to the pain she had experienced with a left ovarian cyst 4 years earlier. The symptoms began during the evening prior to emergency department (ED) presentation. The patient had nausea, but had not vomited, and had a normal bowel movement prior to ED arrival. Her appetite was normal, and she had breakfast earlier in the morning. She denied fever, chills, night sweats, dysuria, or back pain. The patient was menstruating for 3 days prior to presentation, and described this as consistent with prior menstrual cycles. She was monogamous, sexually active, denied any history of sexually transmitted disease, and was not taking oral contraceptive agents. She was only taking acetaminophen for pain, and was allergic to sulfa drugs and tetracycline. She lived with her husband and did not drink alcohol or smoke cigarettes. Dr. Eric Nadel: Are there any questions regarding the initial history? Dr. Laura Bontempo: Can you describe the past gynecological history in more detail? Dr. Lucenti: The patient had a history of numerous episodes of pelvic pain and menorrhagia. The patient was diagnosed with uterine fibroids in 1992. She underwent a myomectomy at that time. In 1997, the patient had a left hydrosalpinx requiring surgical drainage. During that operation a lysis of adhesions was performed. She had cervical dysplasia with cryosurgery in 1988. On physical examination, her temperature was 37.1° C (98.7° F), blood pressure 138/63 mm Hg, pulse 84 beats per minute, respiratory rate 18 breaths per minute, oxygen saturation 100% on room air. The patient appeared comfortable and was alert and oriented. Examination of the head and neck revealed pupils that were equal and reactive to light, no pharyngeal exudate, and no meningeal signs. The cardiac examination revealed a regular heart rate without any murmurs or extra heart sounds. Examination of the lungs revealed clear breath sounds bilaterally. The abdominal examination was remarkable for normal bowel sounds, minimal right lower quadrant tenderness to palpation near McBurney’s point, and no rebound or guarding. Rovsing, psoas, and obturator signs were negative. Rectal examination revealed heme negative stool, and no right or left-sided tenderness. The pelvic examination showed a closed os with minimal oozing of blood. Bimanual evaluation revealed right adnexal tenderness, and no cervical motion tenderness. Examination of the back revealed no costovertebral angle tenderness. The extremities showed no peripheral