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  #1  
Old 05-30-2012
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ObGyn Teenager with abdominal pain!

A 16-year-old girl comes to your office complaining of a stomach ache. She had a lot of fried food and is worried about food poisoning because she has been vomiting. Her only past medical history was an appendectomy at age 8. She takes no medications and denies being sexually active. She is doing well in school and participating in sports. She cannot recall her last menstrual period because she is always irregular. She is unable to use tampons due to discomfort. On exam, she is visibly anxious. Her temperature is 38.8C (102F), pulse 90, BP 122/60 mm Hg. Her abdomen is tense and tender throughout, but most prominently in the suprapubic area. Bowel sounds are scant. She refuses a pelvic examination, but your nurse noted a yellow-green discharge on her underwear when assisting her in undressing. Labs: WBC 15,000, hemoglobin 12, hematocrit 36 with left shift, blood urea nitrogen (BUN) 15, creatinine 1. An abdominal CT is obtained, which shows bilateral complex solid and cystic adnexal masses, the right 7 cm in diameter, the left 5 cm, with adjacent tubular fluid-filled structures likely representing dilated fallopian tubes. Her uterus appears unremarkable. What diagnostic procedure should be performed next?

A. A diagnostic laparotomy
B. A pelvic exam under anesthesia
C. A serum quantitative human chorionic gonadotropin (hCG)
D. A urine for gonorrhea (GC)/chlamydia
E. An exploratory laparotomy
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Old 05-30-2012
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I will go with c first, though the clinical & radiological pic is pointing toward pid but we cant rule ectopic
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Old 05-30-2012
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C- BhCG.

even if it is PID.. still first hv to rule out ectopic..

can be both-- ectopic or TOA
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Old 05-30-2012
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Quote:
Originally Posted by tyagee View Post
A 16-year-old girl comes to your office complaining of a stomach ache. She had a lot of fried food and is worried about food poisoning because she has been vomiting. Her only past medical history was an appendectomy at age 8. She takes no medications and denies being sexually active. She is doing well in school and participating in sports. She cannot recall her last menstrual period because she is always irregular. She is unable to use tampons due to discomfort. On exam, she is visibly anxious. Her temperature is 38.8C (102F), pulse 90, BP 122/60 mm Hg. Her abdomen is tense and tender throughout, but most prominently in the suprapubic area. Bowel sounds are scant. She refuses a pelvic examination, but your nurse noted a yellow-green discharge on her underwear when assisting her in undressing. Labs: WBC 15,000, hemoglobin 12, hematocrit 36 with left shift, blood urea nitrogen (BUN) 15, creatinine 1. An abdominal CT is obtained, which shows bilateral complex solid and cystic adnexal masses, the right 7 cm in diameter, the left 5 cm, with adjacent tubular fluid-filled structures likely representing dilated fallopian tubes. Her uterus appears unremarkable. What diagnostic procedure should be performed next?

A. A diagnostic laparotomy
B. A pelvic exam under anesthesia
C. A serum quantitative human chorionic gonadotropin (hCG)
D. A urine for gonorrhea (GC)/chlamydia
E. An exploratory laparotomy
-c.first rouleout pregnancy,then do D.
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Old 05-30-2012
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Hey isn't the ct scan already rolling out the pregnancy? If so then D
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Quote:
What diagnostic procedure should be performed next?
B. A pelvic exam under anesthesia
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Old 05-30-2012
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Quote:
Originally Posted by Novobiocin View Post
B. A pelvic exam under anesthesia
i initially thought that but then chose otherwise for 2 reasons
1- it doesnt directly say that she refused due to pain
2- even after pelvic exam irrespective of whatever u find.. u will still do BhCG to change your course of management

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Quote:
Originally Posted by mbbs2010 View Post
i initially thought that but then chose otherwise for 2 reasons
1- it doesnt directly say that she refused due to pain
2- even after pelvic exam irrespective of whatever u find.. u will still do BhCG to change your course of management

There is something going on down there and the only way to find out is to do an examination. If Laproscopy was a choice then I will go for that since she has a history of appendectomy and appendicitis is know to cause tubal obstruction.
I don't think pregnancy is the issue here for two reasons:

1. denies being sexually active
2. They have already done the CT Scan (they must have done a urine pregnancy test).

Quote:
She is unable to use tampons due to discomfort.

Last edited by Novobiocin; 05-30-2012 at 03:52 PM.
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Old 05-30-2012
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Quote:
Originally Posted by Aajj View Post
Hey isn't the ct scan already rolling out the pregnancy? If so then D
ans is D indeed.

here is expln

Quote:
Explanation
Option D (A urinalysis for gonorrhea (GC)/chlamydia) is correct. A polymerase chain reaction (PCR) can be performed on a urine sample, avoiding the potential discomfort of obtaining a culture from the cervical os. Following this, administer a combination of broad-spectrum antibiotics to cover both infections if present, plus anaerobes, which are prominent in the flora of pelvic abscesses. Examples of such regimens include: gentamicin plus clindamycin; doxycycline plus metronidazole.
Quote:
Option A (A diagnostic laparotomy) is incorrect. With her history of previous appendectomy, this is unnecessary.
Option B (A pelvic exam under anesthesia) is incorrect. Not likely to add useful diagnostic information that has not already been obtained.

Option C (A serum quantitative human chorionic gonadotropin (hCG)) is incorrect. A urine qualitative hCG should be done first.

this makes sense and i say it matters what question is asking ! dx=PID dx procedure=GC testing

Last edited by tyagee; 05-30-2012 at 04:04 PM.
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