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

A new case study in which the patient, a 17-yr-old African American female, is having ongoing, excruciating pelvic pain. This case study is based upon the very real experience of a woman I met several years ago. The patient’s diagnosis was hard to come by. Put on your thinking caps and see if you can figure it out.

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

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 98.7o F
  • 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.

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.

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SafetyNurse1968

About SafetyNurse1968, BSN, MSN, PhD

Patient Safety Columnist / Educator

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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Specializes in Public Health, TB.

I would do a more complete abdominal assessment: auscultation, palpation, percussion. What kind of diet is she on? Any food sensitivities? Bowel patterns, last bowel movement, any laxative use. Does she play sports? Any chance for an injury?  I would get a CBC and CMP, and an abdominal X-ray. 

I would like to talk to the patient privately, possible with a sexual assault advocate present, about any sexual history and possibility of abuse. If there is any chance of sexual activity, do a SANE exam and would check for STIs and pregnancy. 

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Where her hormone levels measured? Was free fluid noted in the abdomen during Ultrasound? Were her ovaries enlarged? Were there any abnormalities in the appearance of her Fallopian tubes?

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Specializes in Student.

I'm not familiar with the reproductive tract that much but do think its valuable to rule out any general GI and urinary tract concerns once. So I'd:
* Urine culture to make sure no UTI
* General GI assessment (bowel sounds, swelling, pain etc)
* Check for occult blood in stool. Ask about BM in general
* Tests for pancreatitis - verify amylase and lipase levels
* CT scan of abdominal area (stomach, liver, pancreas, gall bladder)
 

Also given that the patient has had ovarian cysts, it might be worth convincing the patient to do cervical scans and a biopsy of the ovaries & cervix if all the above tests come out as normal to rule cancer out.

I'm curious why the patient is hesitant to do any internal exams as well. Is she hiding something? What? She's not pregnant like you said, so I'm wondering what else it could be.

Maybe ask about sexual trauma? Like @nursej22 mentioned above. Maybe that's why she doesn't want to talk about it?

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Specializes in Education, Informatics, Patient Safety.

Great questions everyone!

FIRST FOLLOW UP POST:

Responses to your questions:

  • Abdominal assessment is negative for findings
  • Diet: normal – she eats a wide variety of fruits, veggies, grains and proteins; no food sensitivities noted
  • Bowels: mild constipation reported. Last BM was morning of ER visit. Patient states, “I have to strain sometimes to get it out, but my mom tells me to drink more water – I guess it helps?”
  • She plays sports as noted in the initial post, no injuries
  • Evaluation for sexual assault by SANE is negative, no STIs or pregnancy
  • Ultrasound: no free fluid noted, no enlargement of ovaries, no abnormalities with fallopian tubes
  • Hormone levels: all WNL
  • Urinalysis: negative
  • Negative for occult blood in stool
  • Amylase and lipase levels: WNL
  • Abdominal CT scan: WNL
  • The patient is nervous about having an internal exam because she is 17 and has not had any sexual experiences. She is very private and is embarrassed to have anyone do a lady partsl exam. She is from a conservative, Baptist family. In other words – as far as you can tell, there’s nothing going on  - she doesn’t appear to be hiding anything, but is behaving normally for a young woman of her culture and upbringing.

CA 125 blood test: normal (Blood levels of cancer antigen 125 (CA 125) are often elevated in women with ovarian cancer.

Laboratory Test Results (normal values):

  • Na 140 meg/L (135-145)
  • K 4.1 meq/L (3.5-5)
  • Cl 102 (101-112)
  • HCO3 27 mg/dL (22-32)
  • BUN 18 mg/dL (8-20)
  • Cr 0.9 mg/dL (0.6-1.2)
  • Glu fasting 75 mg/dL (60-110)
  • Ca 9.5 mh/dL (8.5-10.5)
  • TSH 3.9 uU/mL (0.4-6)
  • FT4 18 pmol/L (9-24)
  • PTH 38 pg/mL (11-54)
  • Hb 13.3 g/dL females (12-15.5)
  • Hct 42.5% females (35-45%)
  • Plt 220,000 cu/mm (150,000-450,000)
  • WBC 8.8 x 103/mm3 (4,800- 10,800)

The patient is experiencing chronic pain of unknown etiology (but you will figure it out, I know you will!) Chronic pain affects about 25% of the pediatric population. Researchers have reported prevalence rates of pediatric chronic musculoskeletal pain as high as 40 percent. Chronic pain can take an emotional and financial toll on teens and their families as they seek a cause and answer for their pain and can lead to health care overutilization. Having chronic pain in childhood makes it more likely that you will have chronic pain in adulthood -- one of the most costly medical conditions in the US.

What other ideas do you have?

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Specializes in Education, FP, LNC, Forensics, ED, OB.

Remember to register a "guess" at the diagnosis in the Admin Help Desk.

Go to the Help Desk and start a ticket. Then tell Admins what you think the diagnosis is. You can include rationales, too.

Later ... if you need to amend and/or add to your guess/rationale ... just return to the same ticket for an update.

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Specializes in Public Health, TB.

At this point, I think a diagnostic laparoscopy may be indicated. 

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Specializes in Education, Informatics, Patient Safety.
3 hours ago, nursej22 said:

At this point, I think a diagnostic laparoscopy may be indicated. 

What would a laparoscopic exam tell you that a scan won’t? In light of all the negative scans- I’m  Thinking about risk vs. benefits of procedure requiring general anesthesia.

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Specializes in Public Health, TB.
46 minutes ago, SafetyNurse1968 said:

What would a laparoscopic exam tell you that a scan won’t? In light of all the negative scans- I’m  Thinking about risk vs. benefits of procedure requiring general anesthesia.

My understanding is that the diagnosis I am thinking of can only be made with laparoscopy. Certainly, risks of benefits should be discussed with the patient, but with her repeated complains of excruciating pain I think general anesthesia is an acceptable risk. These days general anesthesia is less riskier than in the past, especially for someone as young and otherwise healthy. 

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Specializes in Education, Informatics, Patient Safety.
59 minutes ago, nursej22 said:

My understanding is that the diagnosis I am thinking of can only be made with laparoscopy. Certainly, risks of benefits should be discussed with the patient, but with her repeated complains of excruciating pain I think general anesthesia is an acceptable risk. These days general anesthesia is less riskier than in the past, especially for someone as young and otherwise healthy. 

I am so looking forward to the reveal on this one and finding out what you are thinking. Thank you so much for participating -makes it so much more interesting!

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I absolutely love your case studies. They are definitely challenging but interesting and insightful. Thanks!

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Specializes in Education, Informatics, Patient Safety.
13 minutes ago, Tj said:

I absolutely love your case studies. They are definitely challenging but interesting and insightful. Thanks!

Thank you so much! That means so much to me!!

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