Question

A 26-year-old G0 presents to the emergency room with eight hours of severe right lower quadrant pain associated with nausea. She has a history of suspected endometriosis, which was diagnosed two years ago based on severe dysmenorrhea. She has been using NSAIDs during her menses to control the pain. She is not sexually active. She is otherwise in good health. Her menstrual cycles are regular and her last menstrual period was three weeks ago. She has no history of sexually transmitted infections. Her vital signs are: blood pressure 145/70; pulse 100; temperature 98.6°F (37.0°C). She appears uncomfortable. On abdominal examination, she has moderate tenderness to palpation in the right lower quadrant. On pelvic examination, she has no lesions or discharge. A thorough bimanual exam was difficult to perform due to her discomfort. Beta-hCG <5 mIU/ml and hematocrit 29%. A pelvic ultrasound showed a 6 cm right ovarian mass. The uterus and left ovary appeared normal. There was a moderate amount of free fluid in the pelvis. What is the most appropriate next step in the management of this patient?

A. Begin oral contraceptives
B. MRI of the pelvis
C. Doppler pelvic ultrasound
D. CT scan of the pelvis
E. Surgical exploration

Answer 1

The most appropriate next step is (E) Surgical exploration due to the acute presentation and ultrasound findings suggestive of a complication such as a ruptured ovarian cyst or ovarian torsion, both requiring prompt surgical management.

Step-by-step explanation:

The most appropriate next step in the management of this patient with severe right lower quadrant pain and a 6 cm ovarian mass is E. Surgical exploration. The presence of a sizeable ovarian mass with associated moderate amount of free fluid in the pelvis can indicate a ruptured ovarian cyst or an ovarian torsion, both of which require prompt surgical intervention. The history of suspected endometriosis, diagnosed two years ago based on severe dysmenorrhea, and the use of NSAIDs indicate that the patient has been managing chronic pelvic pain. However, acute pain as presented here is a concerning symptom that could suggest complications of endometriosis such as the cyst or torsion that need to be addressed immediately to prevent further damage.

While an MRI of the pelvis or a Doppler pelvic ultrasound could provide more information, they would delay the emergency care that might be needed. A CT scan of the pelvis can also be helpful in diagnosing other conditions like appendicitis, but with the information given and the ultrasound findings, surgical exploration is likely the more prudent choice to both diagnose and potentially treat the cause of her acute pain. Oral contraceptives might be an option for managing endometriosis, but they are not the appropriate choice for an acute surgical abdomen, which this case appears to represent.