08-14-2009, 04:03 PM
A 33-year-old nulligravid female presents to her
internist complaining of vaginal and pelvic pain of
8 months™ duration. The pain is diffuse, intermittent,
3/10 in severity, noncyclic, and does not radiate.
It is exacerbated by bending and lifting and is
not related to the timing of her menstrual cycle. She
has internal vaginal pain with intercourse. The pain
does not seem to be affected by urination or defecation.
She has not noted any change in her vaginal
discharge and is in a stable monogamous relationship.
She has tried numerous over-the-counter
medications, including acetaminophen and herbal
remedies, without success. She has seen several
other physicians for this problem, including a gynecologist,
urologist, and gastroenterologist, none of
whom œcan find anything wrong with me.
1). An additional key element of her history today
would include which of the following?
(A) whether or not she has had a workup
for systemic lupus erythematosus (SLE)
(B) if she has had a history of recent travel
outside the country
© screening questions for depression, anxiety,
and physical/sexual abuse
(D) whether or not she has had a pelvic MRI
(E) if she has a family history of colorectal
cancer
24) On physical examination, the patient is afebrile
with normal vital signs. Her urinalysis is unremarkable,
she had a normal pap smear last
month, her gonorrhea/chlamydia screen is
negative, and her pregnancy test is negative.
Her abdominal examination is normal with the
exception of mild tenderness along the lower
portion of her right abdomen which is exacerbated
by raising her head from the table. Her
cervix is normal appearing on speculum examination.
On bimanual examination, she is
tender along both lateral sidewalls of her
vagina, and this tenderness increases with
external rotation of her right hip. She had a
pelvic ultrasound 1 week ago, which showed a
2-cm right ovarian cyst, normal uterus, and
normal left adnexae.
What is your most plausible diagnosis?
(A) ovarian cancer
(B) endometriosis
© musculoskeletal pain
(D) somatization disorder
(E) irritable bowel syndrome
3). The most appropriate management at this time
is which of the following?
(A) pelvic CT scan
(B) laparoscopy
© nonsteroidal anti-inflammatory drug
(NSAID) and physical therapy
(D) selective serotonin reuptake inhibitor
(SSRI)
(E) a high fiber diet and a prescription for
dicyclomine (Bentyl)
internist complaining of vaginal and pelvic pain of
8 months™ duration. The pain is diffuse, intermittent,
3/10 in severity, noncyclic, and does not radiate.
It is exacerbated by bending and lifting and is
not related to the timing of her menstrual cycle. She
has internal vaginal pain with intercourse. The pain
does not seem to be affected by urination or defecation.
She has not noted any change in her vaginal
discharge and is in a stable monogamous relationship.
She has tried numerous over-the-counter
medications, including acetaminophen and herbal
remedies, without success. She has seen several
other physicians for this problem, including a gynecologist,
urologist, and gastroenterologist, none of
whom œcan find anything wrong with me.
1). An additional key element of her history today
would include which of the following?
(A) whether or not she has had a workup
for systemic lupus erythematosus (SLE)
(B) if she has had a history of recent travel
outside the country
© screening questions for depression, anxiety,
and physical/sexual abuse
(D) whether or not she has had a pelvic MRI
(E) if she has a family history of colorectal
cancer
24) On physical examination, the patient is afebrile
with normal vital signs. Her urinalysis is unremarkable,
she had a normal pap smear last
month, her gonorrhea/chlamydia screen is
negative, and her pregnancy test is negative.
Her abdominal examination is normal with the
exception of mild tenderness along the lower
portion of her right abdomen which is exacerbated
by raising her head from the table. Her
cervix is normal appearing on speculum examination.
On bimanual examination, she is
tender along both lateral sidewalls of her
vagina, and this tenderness increases with
external rotation of her right hip. She had a
pelvic ultrasound 1 week ago, which showed a
2-cm right ovarian cyst, normal uterus, and
normal left adnexae.
What is your most plausible diagnosis?
(A) ovarian cancer
(B) endometriosis
© musculoskeletal pain
(D) somatization disorder
(E) irritable bowel syndrome
3). The most appropriate management at this time
is which of the following?
(A) pelvic CT scan
(B) laparoscopy
© nonsteroidal anti-inflammatory drug
(NSAID) and physical therapy
(D) selective serotonin reuptake inhibitor
(SSRI)
(E) a high fiber diet and a prescription for
dicyclomine (Bentyl)