Case Description
The patient in the presented case is a 25-year-old woman complaining about lower abdominal pain and bloating, as well as the absence of menses for eight weeks. The three differential diagnoses identified for this case are lower abdominal pain, bloating, and amenorrhea. This paper aims to outline the laboratory and radiology work-up for the mentioned differential diagnoses and provide a rationale and interpretation for them.
Lower Abdominal Pain
Abdominal pain is a frequent chief patient complaint in the primary care setting. It can be acute, for which patients tend to seek care within the first 24-48 hours after the symptoms occurred, and chronic (Dunlap & Patterson, 2020). For acute pain, diagnosis is made based on patient history, physical examination, and laboratory tests, but imaging is often needed to specify the diagnosis and determine treatment (Dunlap & Patterson, 2020). Before assigning any laboratory and radiology tests, it is necessary to collect patient history and perform a physical examination.
The nature and location of the pain are significant for making a diagnosis. Lower abdominal pain in the right quadrant, combined with abdominal wall rigidity, may be a sign of appendicitis (Bickley, 2021). In women, acute lower abdominal pain can also signify ectopic pregnancy, ruptured ovarian follicles, or pelvic inflammatory disease (Bickley, 2021). Acute pain in the left lower quadrant may be a symptom of diverticulitis, especially when there is a palpable mass (Bickley, 2021).
Since the given patient is a woman of childbearing age, it is necessary to exclude pregnancy first. According to Colucciello (2019), when diagnosing pregnancy, clinicians should not rely on patients’ menstrual history or reports of no recent sexual activity. Instead, they should require women to take a pregnancy test (Colucciello, 2019). Since ectopic pregnancy can be a possible diagnosis in this patient, transabdominal or transvaginal ultrasonography is a feasible choice of a diagnostic test (Colucciello, 2019). While ultrasonography may not always exclude ectopic pregnancy, it can help determine other early pregnancies (Colucciello, 2019). In addition, serial quantitative beta-hCG tests and serum progesterone testing should be performed to identify whether the cause of the patient’s symptoms is an ectopic pregnancy (Colucciello, 2019). If the lab tests result in a positive hCG that increases over time, combined with increased progesterone levels, it will indicate pregnancy.
Bloating
If the patient’s pregnancy is not confirmed, clinicians should consider other diagnoses based on the presented symptoms. In particular, bloating can be a symptom of ovarian cancer, lactose intolerance, and inflammatory bowel disease (Bickley, 2021). Clinicians should rule out ovarian cancer in this patient, especially if the patient has a family history of ovarian or breast cancer or undergoes hormonal replacement therapy (Stewart et al., 2019). Since the symptoms of ovarian cancer – abdominal pain and bloating – are non-specific, women should be tested for CA125 (Funston et al., 2021). If the patient’s level of CA125 is more than 35 U/ml, it is considered abnormal and is a sign of cancer (Funston et al., 2021). At the same time, women with normal levels of CA125 may also have ovarian cancer, so diagnosis cannot rely only on this biomarker (Funston et al., 2021). Therefore, in addition to CA125 testing, clinicians should conduct transvaginal sonography to screen for pelvic masses (Stewart et al., 2019). Finally, the true cancer diagnosis can be made only by means of a transvaginal ultrasound-guided biopsy, which reduced the risk of abdominal wall metastasis (Stewart et al., 2019).
If the given patient appears to be at risk of developing ovarian cancer, several preventive measures should be recommended by clinicians. The risk factors include the family history of cancer, genetic predisposition, endometriosis, uninterrupted ovulation cycles, Lynch syndrome, as well as such modifiable factors as smoking, hormonal replacement therapy, and a diet low in fiber and vitamin D (Stewart et al., 2019). Therefore, clinicians may recommend dietary changes and surgical prevention, such as bilateral salpingo-oophorectomy or tubal ligation (Stewart et al., 2019).
Amenorrhea
The patient presented to the clinic with the absence of a menstrual cycle for eight weeks. According to the definition, amenorrhea is a condition when women do not have menses for the period of three normal menstrual cycles or for three months (Bhaskaran & Sharma, 2020). Therefore, the given patient does not have amenorrhea in a clinical sense. However, combined with other symptoms – lower abdominal pain and bloating – the absence of menses can be a sign of polycystic ovarian syndrome (PCOS). This diagnosis should be considered if, during a physical examination, the patient is presented with a high body mass index, acne, and increased facial hair (Klein et al., 2019). Hormone testing should be performed to confirm the diagnosis; in PCOS, anti-Müllerian hormone, free and total testosterone and dehydroepiandrosterone sulfate are high, and follicle-stimulating and luteinizing hormones are normal (Klein et al., 2019). If the diagnosis is confirmed, clinicians should recommend treatment with combined hormonal contraceptives, regular exercise and healthy eating habits, and regular screening for hypertension and glucose intolerance (Klein et al., 2019). Early management of the syndrome allows for avoiding the development of conditions such as diabetes.
References
Bhaskaran, S., & Sharma, A. (2020). Evaluation of amenorrhea. AOGD Bulletin, 19(9), 7-11.
Bickley, L. S. (2021). Bates’ guide to physical examination and history taking (13th ed.). Wolters-Kluwer.
Colucciello, S. (2019). Assessing abdominal pain in adults: A rational, cost-effective, and evidence-based strategy. Emergency Medicine Practice, 21(6), 1-32.
Dunlap, J. J., & Patterson, S. (2020). Assessing abdominal pain. Gastroenterology Nursing, 43(3), 267-270. Web.
Funston, G., Mounce, L. T. A., Price, S., Rous, B., Crosbie, E. J., Hamilton, W., & Walter, F. M. (2021). CA125 test result, test-to-diagnosis interval, and stage in ovarian cancer at diagnosis: A retrospective cohort study using electronic health records. British Journal of General Practice, 71(707), e465-e472. Web.
Klein, D. A., Paradise, S. L., & Reeder, R. (2019). Amenorrhea: A systematic approach to diagnosis and management. American Family Physician, 100(1), 39-48.
Stewart, C., Ralyea, C., & Lockwood, S. (2019). Ovarian cancer: An integrated review. Seminars in Oncology Nursing, 35(2), 151-156. Web.