Question

A 17-year-old G2P0 female has severe right lower quadrant pain. Her last normal menstrual period was seven weeks ago. She notes that last night she began having suprapubic pain that radiated to her right lower quadrant. This morning, the pain awoke her from sleep. She has had no vaginal bleeding, no nausea or vomiting. The patient's history is notable for two first trimester elective abortions and a history of chlamydia treated twice. Vital signs are blood pressure 90/60; pulse 99; respirations 22; and temperature 98.6°F (37°C). On physical exam, the patient is noted to be curled on a stretcher in a fetal position and says she hurts too much to move. She has rebound and voluntary guarding on abdominal examination. She has severe cervical motion tenderness and rectal tenderness. Her Beta-hCG level is 2500 mIU/ml; hematocrit 24. What is the most appropriate next step in management?

1) Admit for serial examinations
2) Exploratory surgery
3) Recheck Beta-hCG level in 48 hours
4) Administer methotrexate
5) Dilation and curettage

Answer 1

The most appropriate next step in management for a 17-year-old female with severe right lower quadrant pain and a history of chlamydia is exploratory surgery.

Step-by-step explanation:

The most appropriate next step in management for a 17-year-old G2P0 female with severe right lower quadrant pain, suprapubic pain, and a history of chlamydia is exploratory surgery (option 2). The presence of severe pain, rebound and voluntary guarding on abdominal examination, cervical motion tenderness, and rectal tenderness, along with a history of chlamydia, raises concerns for a possible pelvic inflammatory disease (PID) with a tubo-ovarian abscess or ruptured appendix. The patient's vital signs, including hypotension and tachycardia, are concerning for a surgical emergency.

Serial examinations (option 1) may not be appropriate given the severity of the patient's symptoms and the concern for a surgical emergency. Rechecking the Beta-hCG level in 48 hours (option 3) and administering methotrexate (option 4) are not indicated as the patient's symptoms and physical exam findings are concerning for a surgical emergency rather than a medical treatment. Dilation and curettage (option 5) is not indicated as the patient's symptoms and physical exam findings do not suggest a miscarriage or pregnancy complication at this time.