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Chief Complaint
Patient presents to ER with pelvic pain that she says is 10/10. She is crying and hunched over, clutching her stomach. She says, "I can't stand this for much longer. It's been going on for so long. Why is this happening to me? Why can't anyone help me?” She also complains of poor appetite, constipation, and early feelings of satiety after eating. Her mother is worried her child might have cancer.
History of Present Illness
The patient began complaining to her mother of pelvic pain 6 months ago. The pain was a dull ache in her lower left abdomen that would come and go – sometimes occurring with menstruation, sometimes not. It was accompanied by bloating and a feeling of heaviness. When the pain spiked to a 10/10 and the patient began vomiting, her mother took her to urgent care where she was diagnosed with a hemorrhagic ovarian cyst (a fluid-filled sac or pocket on the surface of or within an ovary). Her physician took a "wait and see" approach and after a week, a follow-up ultrasound showed the cyst had resolved.
Over the past two months, the patient has had three trips to the ER for pelvic pain described as "significant, intermittent, vague abdominal and pelvic pain". The mother says, "The last time we were in the ER, they treated us like we were looking for drugs. The last thing we want is pain medication – we want answers. It is just so hard because you keep telling us there's nothing wrong, but my daughter is in agony. We are not crazy! We need help!”
Pelvic Ultrasound has revealed no further cystic involvement. She is not sexually active and pregnancy tests have been negative.
During her first ED visit, she was treated for abdominal migraine with IV Toradol, Compazine, and diphenhydramine, which did relieve the pain briefly.
General Appearance
Appears as stated age, well-nourished, healthy young adult. She looks tired and tense. Her brow is furrowed, and she moves constantly as if attempting to relieve her pain.
Past Medical History
Prior to the first complaint of pelvic pain, the patient has only had a sprained ankle two years ago from running track.
Family History
The patient is the oldest of four children. She has two brothers ages 15 and 10 and a sister who is 12 years old. No significant health issues for any of her siblings.
Mother: 48 years old, no history of gynecological issues or cancer, all four births were lady partsl, full term.
Father: 52 years old, high blood pressure and prediabetes which he is attempting to control with diet.
Social History
This has been a difficult experience for the patient and her family. Her father is a Baptist minister, and her mother directs religious education at their church. She has a large, extended family who have family suppers every Sunday and Wednesday evening. They are a very loving and close family, and it is obvious they want the best for their daughter, but they are struggling to find ways to talk about their daughter's pain. Their daughter is embarrassed and highly resistant to having internal exams. It was very hard for them to accept that oral contraception would be useful for their daughter, but they have been willing to try what providers have recommended if it seems it will help her.
Prior to her pelvic pain, the patient has been very active in school and church. She runs track, plays volleyball, is a member of the honor society, and sings in her church choir. Her activities have been limited due to her pain.
Medications
Oral contraception to limit/reduce recurrence of ovarian cysts (these do not shrink existing cysts), daily multivitamin
PRN Compazine, diphenhydramine, acetaminophen, ibuprofen
Allergies
NKA
Vital Signs
If you've had one ovarian cyst, you're likely to develop more. Most ovarian cysts develop as a result of menstruation (functional cysts). Other types of cysts are much less common. So far, there are no signs of any additional ovarian cysts. Here's a list of other possibilities – what have I missed?
What labs do you want?
What other diagnostic tests should we run?
Ask me some questions! Let's help this poor girl get her life back.
DISCLAIMER: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills.
About SafetyNurse1968, BSN, MSN, PhD
Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is also a mother of four who loves to write so much that she would probably starve if her phone didn’t remind her to take a break. Her work experiences as a hospital nurse make it easy to skip using the bathroom to get in just a few more minutes on the computer. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com. You can also get free Continuing Education at www.safetyfirstnursing.com.
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