welcome to MedCram.com and Board Vitals questions this question comes
from our OBGYN and family medicine question banks a 24 year old female
presents to the emergency department with the acute onset of severe right
lower quadrant abdominal pain her temperature is 98.5 she's doubled over
in pain as had three episodes of vomiting since the onset of pain two
hours ago there's no migration of patients pain
last menstrual period was two weeks ago and was normal she denies any recent
urinary discomfort or abnormal vaginal discharge rapid urine pregnancy test is
negative what emergent study should be ordered on
this patient to confirm the diagnosis is it a CT scan of the abdomen and pelvis
with contrast, B pelvic ultrasound with Doppler flow, C urinalysis, D colposcopy, or
E, GC chlamydia probe, well the key here is
understanding that this is an OBGYN case, right, this is a 24 year old female, the
other thing to notice is that it's been 2 weeks since the menstrual period so
we're probably dealing with the time of ovulation, start thinking about a cyst
the biggest thing to worry about here of course is a twisting or a torsion of the
ovary causing immediate severe pain so the thing that you want to look for are
things to eliminate obviously a GC chlamydia probe is not going to be the
answer because that doesn't come on acutely colposcopy is only going to get
you a look up the vagina to the cervix and you're not gonna be able to see
inside which is where that problem is urinalysis is going to be helpful in
looking at a urinary tract infection but those do not come on this acutely and so
what we're really looking for here is the best radiographic imaging to help
you with that diagnosis is it a CAT scan with contrast or is it a pelvic
ultrasound with Doppler flow so you have to realize that a twisting of the ovary
is actually gonna impinge or eliminate flow in both the vein and the artery if
it's complete if it's partial you'll have somewhat a flow in the artery but
not in the vein so let's take a look a bit more of the anatomy of the ovary
so here you can see that the ovary is very vascular and if you were to have a
cyst on it you could see that there could be some easy twisting and knocking
off of these blood vessels to the ovary which is extremely tender it's extremely
painful and it comes on very quickly and you know this is what we're talking
about here is that you'll see an artery that runs along the ovary and then
branches off but you'll also see branches of vein come along the same way
and so what you can have here is a twisting of the ovary especially if
there's a cyst that's growing on the ovary and what you will see first is a
complete occlusion of the vein until you finally have an occlusion of the artery
so it's possible that if you have no flow that it's definitely a positive for
ovarian torsion no question about it however if there is flow it's still
possible that you've got some flow but it's not completely twisted and so at
that point you're unsure so here if you were to do an ultrasound with Doppler
and you were to have absolutely no flow you could make the diagnosis of a
torsed ovary, a CT scan would be helpful in looking for a cyst but it would not
be as helpful in making a diagnosis of no flow and therefore B is going to be
the right answer