A 13-year-old non-sexually active female presents to the ER with severe abdominal pain. She reports that her period began 3 months ago. During her second cycle she noted right-sided abdominal pain, which was most severe by day 3 of her cycle and continued to worsen until her cycle completely stopped by day 6, at which time the pain was gradually more tolerable. In the subsequent weeks she had progressive difficulties emptying her bladder and ultimately was unable to urinate; consequently she was taken to her local Emergency Room in severe pain. In the ER, she was noted to have urinary retention that was relieved by foley catheterization. A CT scan in the ER revealed a pelvic mass and a single left kidney, but the uterus and ovaries were not well visualized. She was referred to Children's Hospital for further evaluation. You are called to see the patient in the Children's Hospital ER. She complains of mild right lower quadrant pain that is better since the catheterization. She notes her abdominal pain is still present and is intermittent and crampy in nature. She is having normal bowel movements, no nausea, vomiting, fevers or chills. She is currently on her menses.
PAST MEDICAL HISTORY: none.
PAST SURGICAL HISTORY: none.
ALLERGIES: Amoxicillin--> hives.
MEDICINES: none.
SOCIAL HISTORY: she has 4 siblings. She has an older sister and 2 younger sisters and a younger brother. Lives with her mom and dad. She plays soccer.
FAMILY HISTORY: no significant GYN problems.
GYN HISTORY: menarche 3 months ago with normal pubarche. Denies coitarche. She is not yet using tampons.
PHYSICAL EXAM:
VITAL SIGNS: Temperature 98.5 F; Pulse 98; Respiratory Rate 22; Blood Pressure 138/86;
Weight= 54 kg; Height=5’0”; BMI 21.
HEART: Regular Rate and Rhythm
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Positive bowel sounds, soft, nondistended. Discomfort to deep palpation bilateral lower quadrant. No rebound, guarding.
PELVIC: Normal external genitalia, vagina appears patent, no internal exam performed.
RECTAL EXAM: palpable bulge approximately 3 cm above the perineum toward the right side.
EXTREMITIES: no clubbing, cyanosis or edema. no scoliosis.
LABS in the ER:
Na=141 K=3.8 BUN =12 Creatinine= 0.6 Hematocrit=38; Platelets=363
urine pregnancy test =negative AFP =2.4 LDH=180