Case Study This week, complete the Aquifer case titled Family Medicine 20: 28-year-old female with abdominal pain.
After completing your Aquifer Case Stud
Case Study This week, complete the Aquifer case titled Family Medicine 20: 28-year-old female with abdominal pain.
After completing your Aquifer Case Study, answer the following questions using the latest evidenced based guidelines:
• Discuss the questions that would be important to include when interviewing a patient with this issue.
• Describe the clinical findings that may be present in a patient with this issue.
• Are there any diagnostic studies that should be ordered on this patient? Why?
• List the primary diagnosis and three differential diagnoses for this patient. Explain your reasoning for each.
• Discuss your management plan for this patient, including pharmacologic therapies, tests, patient education, referrals, and follow-ups. Family Medicine 20: 28-year-old female with lower
User: kenya leyva
Date: July 21, 2021 11:22PM
The student should be able to:
Conduct a focused history and physical exam appropriate for differentiating between the common etiologies for a patient
presenting with abdominal pain.
Elicit a full obstetric and gynecologic history.
Recognize “don’t miss” conditions that present with abdominal pain.
Propose a cost-effective diagnostic workup for a patient presenting with abdominal pain.
Discuss who should be screened for intimate partner violence.
Develop a health promotion plan for patient of any age or gender that addresses intimate partner violence.
Demonstrate active listening skills and empathy for patient.
Utilize effective listening skills and empathy for patient to help improve patient adherance.
Communicate effectively with patients and families from different cultural backgrounds.
Describe the barriers to accessing and utilizing health care that stems from personal barriers.
Describe the barriers to accessing and utilizing health care that stems from personal barriers.
Significance of the Location of Lower Abdominal Pain
The location of the abdominal pain is important, as it can help narrow your differential diagnosis. For example, diffuse abdominal
pain may represent gastroenteritis, whereas localized right lower quadrant pain is classic for but not limited to appendicitis. Think
about what is in the various quadrants of the abdomen when considering the differential diagnosis of abdominal pain.
Red Flags of Life-Threatening Condition in Patient with Lower Abdominal/Pelvic Pain
There are many signs and symptoms of a life-threatening condition in a patient with abdominal or pelvic pain. Examples include:
Abrupt onset of severe pain
Shock with hypotension and tachycardia
Peritoneal irritation signs
Pulsatile abdominal mass
Absent bowel sounds
Trauma, prior surgeries, or operative scars
History/presence of blood in emesis
History/presence of blood in stool
Severity of the pain
Mass or ascites
G Gravida or number of pregnancies
T Number of Term pregnancies
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P Number of Preterm infants
A Number of spontaneous or inducedAbortions
L Number of Living children
Documenting Follow-Up and Lab Reporting
Documentation of attempts to schedule follow-up visits and inform patients of laboratory results is very important. Failure to reach
a patient by phone or mail should also be documented. If a provider is unable to reach a patient about an important test result
(e.g. an abnormal Pap smear), reaching out to emergency contacts and sending a certified letter should be done to document
every effort to reach a patient.
Abdominal Pain History
Aggravating factors and alleviating factors
Some Common Causes of Lower Abdominal Pain Presenting in Primary Care
Constipation: Patients may give a history of having small, hard pellets for stools, decreased frequency of stooling, harder stools
than usual, or occasionally having loose stools, which may actually signify an impaction, where the patient has soft stool leaking
around an impacted hard stool. This type of stooling pattern is more often associated with irritable bowel syndrome.
Irritable bowel syndrome (IBS): Many patients will describe abdominal pains of varying location, associated with either soft,
frequent, loose stools, or constipation, or an alternating stool pattern. They may also describe abdominal bloating, increased
flatulence, and mucus in the stool. The symptoms of IBS are frequently worse when the patient is under stress, anxious, or
depressed. Symptoms of IBS can be brought on initially by a case of gastroenteritis and can be aggravated by stress, diet, and
change in activity—and the symptoms are often unpredictable. Caffeine and dairy products can make symptoms worse. The
diagnosis is based on clinical history, physical exam, and absence of alarming symptoms suggesting other pathology.
The Rome IV criteria is often used to aid diagnosis of adult IBS:
Recurrent abdominal pain, on average ≥ 1 day per week in past 3 months with two or more of following features:
1. Related to defecation
2. Associated with change in stool frequency
3. Associated with change in stool form (appearance)
Endometriosis: Patients with endometriosis may begin to notice increasingly more painful and heavier menstrual cycles as early
as late adolescence. A patient with endometriosis might indeed have lower abdominal discomfort, often starting after ovulation
during most cycles and continuing through their menstrual cycle. There may also be low back pain or painful stooling. It is not
uncommon for a patient with endometriosis to experience pain with intercourse. Ultrasounds or MRIs may be needed in order to
help diagnose the problem. Laparoscopy may be needed to definitively diagnose, treat, or alleviate symptoms. Hormonal
contraception often stops the pain and the process, thus preserving the patient’s ability to become pregnant later. Genetic factors
are often involved.
Inflammatory bowel disease (IBD): Patients with IBD usually have some combination of abdominal pain, bloody diarrhea, and
frequent stooling. The onset of symptoms frequently occurs in the late 20s or early 30s. The patient may ultimately be diagnosed
with either ulcerative colitis or Crohn Disease. Diagnosis is made through specific radiological findings on barium enema, small
bowel follow-through, and by colonoscopy.
Muscular pain or musculoskeletal pain is generally reproducible. On exam, there is usually point tenderness to palpation of
the affected muscles. The pain may recur during certain activities or when the offending position is (re)assumed.
Psychosomatic pain: Symptoms from this type of pain are variable and can be associated with or aggravated by other etiologies
such as IBS or gastritis. The pains can occur anywhere throughout the abdomen. They usually present as an atypical pain pattern,
occur in a depressed or otherwise mentally ill patient, and may point toward a psychogenic cause. This is a diagnosis of exclusion.
Stress: The patient’s symptoms and pains tend to be increased when the patient is under increased stress or is involved in other
negative interactions. The patient may present with a whole constellation of other stress-related symptoms, such as headache,
depression, anxiety, appetite changes, and sleep disorders. Stress can also aggravate other conditions, such as irritable bowel
syndrome. This diagnosis, which is related to psychosomatic disease, is one of exclusion.
Urinary tract infection (UTI): Symptoms may include lower abdominal or suprapubic pain, urinary frequency, burning with
urination (dysuria) that is frequently worse at the end of the urinary stream (terminal dysuria) and which can also involve
hematuria. There may even be lower back pain in severe infections that involve the kidney. Among patients with female genitalia,
the onset of symptoms may be related to recent sexual intercourse. UTI is a common condition and should always be considered
in patients with lower abdominal pain.
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Vaginitis: The patient’s symptoms and concerns will vary depending on the cause of the discharge. She can present with a
vaginal discharge that is watery to pasty; it may be malodorous; discomfort can vary from itching to burning, and there may or
may not be pain with intercourse (dyspareunia) and pelvic pain. Being at risk for sexually transmitted infections widens the
differential, and the use, or lack thereof, and the type of contraceptive used impacts that risk. An expanded history is needed in
this case. Examination of the discharge under the microscope, or sending a vaginal swab and cervical cultures to the lab, is
Intimate Partner Violence: Screening Recommendations, Prevalence, and Complications
The American College of Obstetrics and Gynecology suggests screening all patients who come to them (family planning patients,
all ob-gyn patients, and all prenatal patients) at first visit, at each trimester, and at the postpartum visit. It may help to preface
asking such questions with a statement such as: “Because intimate partner violence (IPV) is so common, I ask all of my patients
The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen women of childbearing age for IPV, such as
domestic violence, and provide or refer women who screen positive to intervention services. (Level of Evidence: B)
This is routinely done at annual exams or when red flags are present.
Here is a good resource regarding screening for intimate partner violence.
It is important to be aware of IPV when addressing our patients, as approximately 25% of women in the U.S. report being
victimized by an intimate partner at some point in their lifetime. While the majority of IPV victims are women, they can be any
gender, occur in both heterosexual and same-sex relationships, and across all socioeconomic, age, and ethnic divides.
In addition to the trauma incurred, the rates of chronic disease—including heart disease, diabetes, depression, and suicide—are
significantly higher in victims as well as in adults who were victimized as children as a result of direct abuse and exposure to IPV.
Symptoms and Conditions Experienced More Frequently by Victims of IPV Red Flags for Intimate
Individuals who were victimized by their intimate partner are more likely to experience:
Migraines, frequent headaches
Chronic pain syndrome
Heart and blood pressure problems
Stomach ulcers, frequent indigestion, diarrhea, constipation, irritable bowel syndrome, spastic colon
Pain during sex (dyspareunia), dysmenorrhea, vaginitis, pelvic inflammatory disease, chronic pelvic pain syndrome, and
other gynecological diagnoses
Invasive cervical cancer and preinvasive cervical neoplasia
Depression, anxiety, and post-traumatic stress
Unexplained or poorly explained findings on physical exam
Red flags for intimate partner violence include:
Delay in seeking medical care
Non-compliance with treatment plan
Partner insisting on staying close and answering questions directed to patient
Hesitancy or not answering questions or inconsistent or incorrect answers given to questions
Shyness or reticence in answering questions
Explanation of problem or incident does not match severity of findings
Facilitating Discussion About Intimate Partner Violence
There are several nonjudgmental ways to ask about intimate partner violence. Examples include:
“Do you feel safe at home?”
“Because violence is so common, and there are so many forms of violence, I am asking all my patients about it. Is anyone
now or has anyone in the past hurt you emotionally, physically, or sexually. Is anyone threatening you?”
“All couples disagree at sometime. What happens when you disagree/fight/argue?”
“Does your partner ever force you to do things you do not want to do or keep you from doing things you want to do?”
“How do you handle money issues in your relationship?”
“I often see the type of symptoms that you have in people who are being hurt at home or in a relationship. Do you think that
this might be happening to you?”
There are lots of things you can do to facilitate discussion about IPV.
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Many clinics will ask a screening question of all patients during the triage process. Asking the patient, “Do you
feel safe at home?” follows the vital signs and questions about whether or not the patient is having any pain.
This open-ended question allows the patient to share information they might have about feeling unsafe at
home, in their neighborhood, or where they live, work, or shop, or feeling threatened or actually being abused
by someone. This question is appropriate for any age, gender, or socioeconomic class. It may take several
visits for the patient to feel comfortable enough with the provider to discuss such a sensitive issue.
Create a safe
Hang posters on the clinic walls and place brochures about safety, particularly in private areas like bathrooms
and exam rooms. These should also contain information addressing cultural differences and acknowledging
varied relationships and backgrounds.
Never interview with the suspected perpetrator present. In order to have the partner leave the room, you can
cite protocols such as, “I always do this part of the exam just with the patient. You can join us again when we
are done.” Or, “I begin the visit with the patient alone. If you have questions after, we can meet together.”
If the partner insists, then attempt to separate the two by taking the patient to obtain a urine sample or
another test outside of the exam room.
Infants and toddlers three years old or younger can stay with the parent, but it is recommended that if the
child/children accompanying the parent are older than three, you should meet with the patient alone.
Update and review HIPAA forms and make sure that all staff are aware of how to use them. Be sure to tell the
patient that anything discussed in the room will not be shared with anyone not directly involved with their
care, including their partner and family members.
Interviewing can begin with indirect questions such as, “Tell me about your relationship,” but should include a
direct assessment of safety, including questions regarding weapons in the house and danger or possible harm
to the children or pets.
Know your local
All states require reporting of child abuse and some require reporting of intimate partner violence. Be open
with your patient about your legal constraints.
Consider using a telephone service for interpretation if an appropriate professional interpreter is not present in
the office. Do not use a friend or relative.
nonjudgmentally Validate the patient’s concerns and the fact that abuse is not the fault of the victim.
Handling Children During a Sensitive History and Exam
It is generally preferred to have children outside the room during a pelvic or genital exam of the parent. Depending on the age of
the child, some parents may prefer to have the child sit in the room in a corner and face away from the exam table, or keep a
sleeping child in a stroller in the room with them. The clinician may have sensitive questions to ask; the parent-patient may not
want the child to see them undressed and undergoing this exam.
There is frequently someone on staff who will watch or entertain the child or children during this portion of the exam. Or the
parent may have come to the clinic with a friend or relative with whom the child can stay in the waiting room during that portion
of the visit.
It is also important to have a chaperone in the room for the exam for legal reasons and for protection of the clinical staff. This
person should be named in the chart note.
Symptoms of Exposure to Domestic Violence in Children and Adolescents
Obvious physical signs of physical or sexual abuse
Behavioral or emotional problems, such as increased aggression, increased fear or anxiety, difficulty sleeping or eating, or
other signs of emotional distress
Chronic somatic concerns
30% to 60% of perpetrators of intimate partner violence also abuse children in the household.
Intimate Partner Violence Safety Assessment
1. Increasing severity of violence
2. Presence of gun in the house
3. Threats to kill or commit suicide by either victim or abuser
4. Use of drugs or alcohol by victim or abuser
5. Victim trying to leave or left recently
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6. Harm to children
Increasing Severity of Intimate Partner Violence
1. Verbal abuse, insults, yelling
2. Throwing things, punching wall
3. Pushing victim or throwing things at victim
5. Kicking, biting
6. Hitting with closed fist
7. Attempting strangulation
8. Beating up; punching with repeated blows
9. Threatening with weapon
10. Assault with weapon
Escalating Cycle of Intimate Partner Violence
Intimate partner violence is a pattern of increasing episodes of violence in which one partner exerts control over another through
intimidation, physical and/or emotional violence, and threats. It is common for there to be a tension-building phase, a crisis phase
when overt violence is likely to occur, followed by a calmer phase when the abuser might ask for forgiveness and even be
affectionate. Unfortunately, in most cases, the cycle begins again and often the violence is increasingly severe.
Documenting a Case of Suspected Intimate Partner Violence
When documenting a history of abusive behavior, use the patient’s own words in quotes and fill in names after pronouns are used.
Example: “then he (John Smith)…”. Use neutral language. Example: “patient states”, not “patient alleges,” which may give a false
impression of disbelief.
Give a detailed description of the patient’s appearance, behavioral indicators, injuries and stages of healing, and health
conditions. If the patient consents, use photos to document injuries; one with a face included in the photo, and then close-ups of
the injury. If photos are not possible, draw and describe injuries on a body map in blue ink as this is difficult to alter/reproduce.
Document recommendations for support and follow-up as well as materials given to the patient.
Document abuse history as reported by patient in the subjective. The subjective section is meant to document the patient’s
experience and verification is not applicable. Include any laboratory and radiology tests ordered with results to maintain a
complete record for the patient. Document results of health and safety assessments and plans for follow-up as well as referrals
and materials given to the patient. Document recommendations for support. If the patient was referred for a post-rape exam,
document the referral site. Maintain strict confidentiality and safeguard the chart rather than limit the contents for best care
Adequately Addressing Your Patient’s Needs Within Time Constraints
It is a common scenario to see a patient that is scheduled for an acute visit, but the situation requires more time to be adequately
addressed. Prioritize the most acute or high risk issues raised during this visit and focus on these, and then emphasize the
importance of follow-up and schedule a follow-up visit as soon as possible.
The Role of the Health Care Provider in the Care of a Victim of Intimate Partner Violence
It is important to acknowledge the abuse, recognize the health implications, and share this with your patient.
While you may not always agree with the decisions your patient makes to stay or escape, it is important that you
support their decisions. They have a greater understanding of the complexity of the problem, and have more
information on which to base their actions.
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Address the level of risk and safety issues for your patient. Provide information for them to go to a safe haven if
needed. As lack of a telephone or computer (or monitoring of their use) often make it unsafe or impossible for
victims to contact IPV resources from home, it is important not only to give contact information to the patient, but
also to offer a means for them to contact services while in your office. One should be aware that the person inflicting
the violence might check the patient’s/victim’s phone and computer for recent phone calls, website visits, and
Cultural differences can give the appearance of abuse, be accepting of practices some might consider abusive, and
can inhibit the ability to interview or support a victim. Practicing sensitivity in caring for patients from different
backgrounds is key to a supportive patient-clinician relationship.
When children or other vulnerable persons who are less able to make decisions on their own behalf are in the home,
consideration must be given to the impact of the abuse on them physically and mentally as well as their safety.
Even in states where reporting abuse towards a domestic partner is not mandated, the impact or abuse on a child or
other vulnerable person may be and will supersede the desires of the victim to not alert social services.
It is not possible for a clinician to solve the problem of IPV for an individual. Statistically, the most dangerous time for a victim is
when they escape an abusive relationship. While it is hard to accept, sometimes it may be safer for a victim to stay with the
perpetrator. Clinicians are not in a position to stop the abuse. You can make recommendations in terms of decreasing the victim’s
level of risk by providing resources to the patient, limiting access to weapons, and developing an escape plan with a victim’s
advocate. Safety planning takes time and expertise. While some clinicians will take the time to be trained to be effective at this, it
is probably best to utilize experts who are associated with IPV agencies if available or to train a staff member to serve this role.
Reporting laws differ from state to state, so you need to know what the laws are where you are working. Whenever a child is
abused as a result of IPV, either intentionally or unintentionally, state law requires health care providers to report this abuse to
child protection services. Mandated reporters would also report any high-risk situation of IPV in which children are at risk.
However, state laws are less clear about whether exposure to IPV in the absence of injury or serious risk of injury to the child
would require a report to children’s protective services.
In some states, stringent rules/laws require mandated reporters to notify child protection services whenever a child is in the home
and has been exposed to a parent’s abuse, whether or not the child has been directly abused. Proponents of this definition point to
the ample documentation of the overlap between adult IPV and child abuse and the adverse psychological effects on children who
witness IPV. Opponents of this policy believe it penalizes women for abuse that they have no control over and may discourage
women from seeking help. It also could elevate the level of risk for the victim.
In other states, a child’s exposure to IPV does not automatically require a mandatory child protection report. The provider has
wider discretion to assess whether a child has been directly involved and what other factors may exist to put the child at risk. In
these states, a provider would take into account the existence of direct injury to a child, the potential danger of the situation, and
the capacity of the mother to keep her children safe in deciding whether to notify Child Protective Services (CPS).
The rules for victims who are adults and are not disabled vary dramatically from state to state, from mandatory reporting for
evidence of abuse to reporting only if the victim asks the clinician to do so. Contact your local Domestic Violence helpline and ask
what the rules are for the community in which you work. You can find out about your local resources by calling the National DV
Hotline at (800) 799-SAFE, TTY (800) 787-3224.
Recommended Studies for Evaluation of Lower Abdominal Pain
thin prep Recommended in the setting of previous abnormal results.
This is a quick test which should be done as it could indicate inflammation (white blood cells) or diagnose
trichomonas, bacterial vaginosis, or yeast vaginitis.
Chlamydia and gonorrhea can present with a yellow discharge, abdominal pain, and dyspareunia. This is the
preferred method for diagnosis of chlamydia and gonorrhea because both can be performed using the same
sample, and the sample can be endocervical, urethral, vaginal, oral, or urine.
dipstick Helpful to rule out a urinary tract infection (UTI).
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Should be performed on any patient who is physically able to be pregnant.
RPR Should be done as part of the STI screen to rule out syphilis.
HIV Should be done as part of the STI screen.
HPV Consider ordering a reflex HPV. Reflex refers to the fact that an abnormal Pap will automatically be tested for HPV.If the Pap is normal, the HPV testing will not be done.
The pelvic exam, urine pregnancy test, and STI testing will help guide the need for an ultrasound to evaluate a
possible pelvic mass, the size of uterus and ovaries, to confirm the location of a pregnancy, or to rule out an
inflammatory or infectious process.
Colposcopy Colposcopy is not indicated until the results of the Pap are back. If the Pap is abnormal, and/or if high-risk HPV ispositive, a colposcopy may be indicated. Follow the ASCCP guidelines for follow up of abnormal PAP
While this is a good test for gonorrhea, a separate test needs to be done on vaginal or urine samples. However,
this is still the preferred method for sexual assault tests, for tests of cure, and for oral and rectal specimen.
HCG beta sub This is generally not indicated because of the sensitivity of the urine pregnancy test. If the results of the urinepregnancy test were inconclusive, a blood test such as HCG Beta Sub would be needed.
Severe / Life-Threatening Causes of Abdominal Pain
Patients with appendicitis often start with visceral pain that is dull and in the periumbilical region; within a short
time the pain classically localizes; presentation is usually of fairly acute onset with moderate to severe right
lower quadrant pain. There is often a history of nausea and/or vomiting. There are usually some changes in the
patient’s bowel movements.
Ectopic pregnancy is a medical emergency. Early medical treatment reduces the need for surgery, but if the
fallopian tube is in danger of rupture, surgical intervention may be necessary. Patients present with divergent
symptoms ranging from no pain and normal menses to intense pain and irregular or absent menses. A good
history, the physical exam and lab testing (always get a pregnancy test if the patient has a uterus) are crucial for
this diagnosis. Imaging is also usually needed. You need the date of the patient’s last menstrual period (LMP), her
menstrual history, most recent intercourse dates, the types of contraception used currently and used in the past
/ever used, history of any vaginal or pelvic infections, and history of previous ectopic or normal pregnancies.
While endometriosis is not typically life-threatening, it can be severe. The majority of patients are of reproductive
age and present with cyclical pelvic pain, following the menstrual cycle in patients with regular menses. The
location and pattern of the pain can vary widely, depending upon which organs have been affected. For example,
those with bladder involvement may present with urinary frequency, urgency or dysuria. Endometriosis may also
present as infertility in an otherwise asymptomatic patient or as an incidental finding during surgery.
Patients with ovarian problems generally have lower abdominal or pelvic pain. Pain from ovarian torsion or
ruptured cyst or ectopic pregnancy may be very severe and usually has a sudden onset. Patients often present to
the emergency department due to the pain, and this is appropriate since imaging is usually necessary to
determine the exact cause of the pain. In several cases, the pain from ovarian problems may persist for several
weeks. It is often aggravated by intercourse or strenuous activity.
Patients with pelvic inflammatory disease (PID) might have abdominal or pelvic pain, which is worse with sexual
intercourse or with activities such as running or jumping, which cause jarring of the pelvic organs. This diagnosis
has significant morbidity, which increases with the severity of the disease and with the length of time to
diagnosis. Studies show that approximately one in four patients who had a single episode of PID later
experienced tubal infertility, chronic pelvic pain, or an ectopic pregnancy, as a result of scarring and adhesions.
Tubal adhesions leading to infertility have been reported to occur in 33% of patients after their first episode of
PID, and up to 50% after the second pelvic infection.
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