UWOrld Q: 38 year old woman with abdominal pain

[medInUSA]

38 year old woman come to the emergency dept, due to sudden onset severe stabbing mid epiastric pain 30 min ago. Now she has lower abdominal pain. She has a history of peptic ulcer disease. LMP was 30 days ago. Physical exam shows tenderness of the entire abdomen on palpation: there is guarding and marked rebound tenderness; there is no shifting dullness; bowel sounds are absent. Her temp is 36.8, BP is 160/90, pulse is 110 and resp are 25 per min. Hb 13.1, Hct 43%, WBC 10,900

what is the most appropriate next step in management?

a) Upright Abdominal X-ray
b) pregnancy test


Of course I chose pregnancy test since this is a woman in her reproductive age with abdominal pain !!!!!

No!!!!
the anser is Upright Abdominal X-ray,

Explanation "the woman has clear signs of peritoneal irritation, immediately after the onset of the pain. Most likely, a peptic ulcer has perforated and highly irritating stomach or duodenal contents have spilled into peritoneal cavity and have descended producing lower abdominal pain.
Many gynecological conditions could give a similar complaints but because of the patients' PMH perforated PU should be ruled out first."

I think pregnancy test should be done first in any woman of reproductive years with abdominal pain. What do you guys think. Is this a bad question or am I wrong ?

---

Members don't see this ad.

 

[stookie]

I think what they are trying to get at is that a 38 y.o. woman is less likey to be pregnant at that age, and the whole LMP thing was ment to be a distraction. Also, you need to rule out surgical emergencies first!
I found that you need to read their minds with UW, to answer some of their questions. I hope it's not like that on step 2!

 

[funshi baba]

i would have picked Abd X-ray. But i think your reasoning is perfectly fine. In reality, u would probably do both at the same time.

 

[FutureInternist]

No matter how small the likelihood you have to do pregnancy test before any X-rays.....if you don't just make sure a "medication error" occurs so she can't sue you for killing her fetus later. 😀

Bad question.

 

[Scaredshizzles]

No matter how small the likelihood you have to do pregnancy test before any X-rays.....if you don't just make sure a "medication error" occurs so she can't sue you for killing her fetus later. 😀

Bad question.

For one the idea that one lil x-ray is gonna cause a defect is bogus...A very slim chance perhaps, but even if she were pregnant, you MUST get an X-ray in this case...you have no other option...doing a sonogram looking for free air would be very time consuming and less accurate. Also, the rapid pregnancy tests they do in the ER are usually with urine...A woman in that much pain might not be so likely to give you urine...you could cath her I suppose, but again, all of this takes time. And if you're concerned about a rupture eptopic, almsot zero chance of that...her lmp was 4 weeks ago, which means at most, she has a 2 week old conceptus in there....2 week olds are not big enough to rupture a fallopian tube.

 

[RussianJoo]

here's the answer.. the lady has perotineal signs and history of peptic ulcer disease, which means perforated ulcer... the first test you'll get is Abd X-ray to see free air under the diaphragm.

What you have to know to answer this question correctly though is that even if she's pregnant, she's at most at 2 weeks gestation and since the three germinal layers haven't formed yet the embryo will either survive intact or die if there's any sort of anomaly. this is when most abortions happen and the pt doesn't even know she was pregnant. the time period with the greatest teratogenic risk is from 3 to 15 weeks gestation when organ development takes place. Also you have to know that no single diagnostic procedure has enough radiation exposure to threaten the development of the pre-embryo embryo or fetus. you need more than 5 rads to have an increase in risk of developing anomalies, and a single x-ray has well under 1 rad. So even though we don't like to give unnecessary radiation to pregnant women 1 x-ray isn't going to do anything, she'll get more radiation if she went to the beach for the day.

another excellent question and something that's totally fair game for the USMLE.

 

[Scaredshizzles]

here's the answer.. the lady has perotineal signs and history of peptic ulcer disease, which means perforated ulcer... the first test you'll get is Abd X-ray to see free air under the diaphragm.

What you have to know to answer this question correctly though is that even if she's pregnant, she's at most at 2 weeks gestation and since the three germinal layers haven't formed yet the embryo will either survive intact or die if there's any sort of anomaly. this is when most abortions happen and the pt doesn't even know she was pregnant. the time period with the greatest teratogenic risk is from 3 to 15 weeks gestation when organ development takes place. Also you have to know that no single diagnostic procedure has enough radiation exposure to threaten the development of the pre-embryo embryo or fetus. you need more than 5 rads to have an increase in risk of developing anomalies, and a single x-ray has well under 1 rad. So even though we don't like to give unnecessary radiation to pregnant women 1 x-ray isn't going to do anything, she'll get more radiation if she went to the beach for the day.

another excellent question and something that's totally fair game for the USMLE.

This is definitely correct for answering questions and what attending will tell you. Although the cumulative radiation part I always disagree on....Radiation exposure like this is hit or miss imo...If you get 10 CTs, then the odds of getting an anomaly are 10x greater than if you get one---but the idea of having zero risk if you only get one is pretty silly....Since zero times 10 would still be zero. But it is generally considered a negligible risk. The chances of having an anomoly in even a perfectly healthy pregnancy in a young woman is at least 3% or so anyway...which is considerably higher than the risk from any given diagnostic test.

 

[docmd2010]

to further strengthen the Abd xray answer, if you suspect ruptured ectopic, usually a history of PID or previous ectopics is given, not that this is a deciding factor but also something to think about. if they say "has a hx of PUD" usually think rupture first.

 

[Cliff Huxtable]

i would have picked Abd X-ray. But i think your reasoning is perfectly fine. In reality, u would probably do both at the same time.

I thought weeks 3-8 of gestation are most sensitive to teratogens and such. A LMP of 30 days ago is about 4 weeks. If she was pregnant, couldn't x-rays do damage?

 

[medInUSA]

I thought weeks 3-8 of gestation are most sensitive to teratogens and such. A LMP of 30 days ago is about 4 weeks. If she was pregnant, couldn't x-rays do damage?

If the LMP was 30 days, that was the menstrual phase.
For most women the ovulation happens around day 14 or about two weeks after the LMP. Therefore as RussianJoo stated above the age of the fetus is actually about 2 weeks. Thus low risk or teratogenicity since the embryo will either survive intact or die b/c the three germ layers haven't formed yet

 

[Cliff Huxtable]

If the LMP was 30 days, that was the menstrual phase.
For most women the ovulation happens around day 14 or about two weeks after the LMP. Therefore as RussianJoo stated above the age of the fetus is actually about 2 weeks. Thus low risk or teratogenicity since the embryo will either survive intact or die b/c the three germ layers haven't formed yet

Thanks!

 

[Psych2014]

I think Risk Vs. Benefit is the key principle here.
The benefit of quick dx of this potentially life threatening situation (free air on AXR would lead to laparotomy), and the desire to save the life of both the mother and child, X-ray is justified, especially considering the extremely low chance of teratogenicity. that's my opinion.

 

[Rendar5]

Test-world: woman is not pregnant as her stated LMP is correct, or if she is it'll be a 2week fetus, and this question is a PUD question where everything points in that direction, esp. absence of bowel sounds and initial epigastric pain despite later lower abdominal pain.


Real-world: woman potentially has a 6 week fetus (LMP may not have been an actual period), the woman needs both tests as ruptured ectopics can cause acute abdomen too. Both tests are potentially easy and fast. The initial test is whichever one you get to first.