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Review Question - QID 100511

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QID 100511 (Type "100511" in App Search)
A 17-year-old woman presents to the emergency department with abdominal and pelvic pain. She states it started 3 days ago and it has been getting gradually worse. She states it is diffuse and is located over her abdomen, pelvis, and inside her vagina. She also endorses vaginal pruritus and a discharge from her vagina. The patient works in an ice cream parlor and is sexually active with multiple different partners. Her temperature is 98.0°F (36.7°C), blood pressure is 122/80 mmHg, pulse is 82/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is notable for a foul smelling vagina with a thin, white discharge. Her abdomen is diffusely tender. The patient is noted to be itching her vagina during the exam. Which of the following is the most appropriate initial step in management?

Cervical swab and culture



CT abdomen/pelvis



KOH prep



Urine hCG



Wet mount



Select Answer to see Preferred Response

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Female patients of reproductive age who present with uropelvic or abdominal complaints should always be screened for pregnancy with a urine hCG before further more invasive tests.

The differential diagnosis of abdominal pain is very broad in a female patient. Possible life-threatening diagnosis can include appendicitis, mesenteric ischemia, cholecystitis, cholangitis, perforated viscus, ovarian torsion, volvulus, small bowel obstruction, ectopic pregnancy, and heterotopic pregnancy. In young female patients, the workup should always start with a urine hCG to rule out an obvious pregnancy. Even if pregnancy is not considered to be in the differential, if a patient is pregnant it may affect subsequent care and imaging studies (such as ordering CT scans considering the radiation exposure). After a urine hCG results, then further more invasive testing can be performed.

Incorrect Answers:
Answer 1: Cervical swab and culture may be indicated in the workup of this patient if no other etiology of her symptoms is discovered. Her thin, white vaginal discharge is more suggestive of a physiologic discharge.

Answer 2: CT abdomen/pelvis would be indicated after initial laboratory tests are negative and the patient has focal tenderness. It would be appropriate in this patient; however, her urine hCG should result first.

Answer 3: KOH prep is generally not indicated in the workup of candida vaginitis which is a clinical diagnosis. It presents with a thick, white discharge with intense pruritus. This diagnosis is possible in this patient; however, she should have a urine hCG performed first.

Answer 5: Wet mount would be indicated to diagnose trichomoniasis which presents with a strawberry cervix, pruritus, and a frothy and green discharge. The treatment is metronidazole.

Bullet Summary:
A urine hCG should be ordered in women of reproductive age with abdominal or pelvic symptoms.

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