Agonizing Pelvic Pain: What's Going On with this 17-year-old? | Case Study

SafetyNurse1968, ADN, BSN, MSN, PhD

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

BP 132/85 sitting, RA
HR 89
RR 17
T 98.7^oF
HT 5'4”’
WT 130 lbs

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?

Dermoid cyst
Cystadenoma
Endometriosis
Ovarian torsion
Pelvic infection
Cancer
Uterine fibroids
Pelvic inflammatory disease
GI issues
Porphyria
Abdominal migraines (was the ED doc right?)
Appendicitis
Mesenteric artery ischemia
Wilson's syndrome
Autoimmunity

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.