QUESTION 11

 A 22-year-old woman comes to the emergency department with right upper quadrant pain that has worsened over the past day The

pain initially began 5 days ago in the lower abdomen after she returned from a trip to South America. The right upper quadrant pain

increases with deep breathing She now has fevers, chills, and vomiting The patient has no diarrhea, constipation, or changes in

stool color. She has no medical conditions or previous surgeries The patient is sexually active with a male partner and does not use

contraception She is currently on her menstrual period but reports increasing irregularity over the last 3 months with occasional

spotting She does not use tobacco, alcohol, or illicit drugs Temperature is 38.9 C (102 F}, blood pressure is 100/70 mm Hg, and

pulse is 104/min. BMI is 21 kg/m2 Examination shows right upper quadrant tenderness, and the lower abdomen is diffusely tender

without guarding Bowel sounds are present There is no costovertebral angle tenderness. Skin is normal without a rash. Urine

pregnancy test is negative Which of the following is the most likely diagnosis for this patient?

QA Acute appendicitis

0 B. Acute cholecystitis

0 C. Acute pancreatitis

0 D. Acute viraI hepatitis

0 E. Pelvic inflammatory disease

0 F Perforated peptic ulcer

0 G. Ruptured ectopic pregnancy

0 H. Ruptured ovarian cyst

Pelvic inflammatory disease (PIO) typically presents with fever, lower abdominal tenderness, mucopurulent cervical discharge,

and cervical motion and uterine tenderness. lntermenstrual spotting can occur due to cervicitis, and abdominal pain due to PID

typically worsens with menses. Infection can extend from the upper genital tract to spread throughout the abdomen and cause liver

capsule inflammation (eg, perihepatitis or Fitz-Hugh-Curtis disease), resulting in vomiting and slightly elevated transaminase levels.

Patients with hepatic involvement present with symptoms of acute PID (fever, lower abdominal pain) as well as pleuritic right upper

quadrant pain (eg, increased pain during inspiration)

Risk factors for PIO include age <25 and sexual activity without barrier contraception Routine screening and treatment for gonorrhea

and chlamydia infection prevent associated long-term complications (eg, infertility, ectopic pregnancy, chronic pelvic pain) and

progression to PIO. Treatment of acute PIO with perihepatitis includes hospitalization and intravenous antibiotics.

(Choice A) Appendicitis presents with fever and periumbilical pain that migrates to the right lower quadrant rather than the right upper

quadrant

(Choice B) Cholecystitis presents with localized right upper quadrant tenderness with no associated lower abdominal pain. Affected

patients are typically age >40 and obese.

(Choice C) Acute pancreatitis presents with epigastric and back pain rather than right upper quadrant and lower abdominal pain.

Risk factors include obesity and alcohol abuse.

(Choice D) Acute viral hepatitis can present with upper abdominal pain in patients with recent travel to endemic regions Patients

typically have associated jaundice and changes in stool color.

(Choice F) Patients with a perforated peptic ulcer are afebrile with epigastric pain and have absent bowel sounds, guarding, and

abdominal rigidity on physical examination.

(Choice G) Ruptured ectopic pregnancy can present with diffuse abdominal pain due to hemoperitoneum. Patients are afebrile and

have signs of an acute abdomen (eg, rebound, guarding). This diagnosis is excluded by the negative pregnancy test

(Choice H) A ruptured ovarian cyst can cause djffuse abdominal pain; it is not associated with fever.

Educational objective:

Pelvic inflammatory disease (PIO) can be complicated by perihepatitis (eg, Fitz-Hugh-Curtis disease). Patients typically have right

upper quadrant pain in addition to classic PID symptoms (eg, fever, lower abdominal pain), and are young, sexually active, and not

using barrier contraception.