# Fainted at work with lower abdominal pain, a 27-year-old: an emergency case to work up

> An emergency case for medical students: a young woman who collapsed at work after a day of lower abdominal pain, pale, sweaty and with shoulder pain. The first steps, what to ask, first tests and the differential.

- Obstetrics & Gynecology · Intermediate · about 15 minutes
- Web page: https://www.medikarya.in/case-studies/27-year-old-woman-who-fainted-at-work-with-pain-low-in-her-belly
- Work up this patient: https://www.medikarya.in/case-studies/27-year-old-woman-who-fainted-at-work-with-pain-low-in-her-belly

## How the patient presents

A young woman collapsed at her office after a day of pain low in her belly. Her colleagues brought her in; she is pale, sweaty and says her shoulder hurts too.

## Why lower abdominal pain with collapse in a young woman matters

Any woman of reproductive age with abdominal pain and a faint needs a pregnancy test straight away, whatever she says about her periods or contraception. Pain felt at the tip of the shoulder can mean blood or fluid irritating the diaphragm. Resuscitate while you find the source.

## What to ask in the history

- The pain: when it started, where, which side, what it is like
- The faint: what happened, how quickly she came round
- Last menstrual period, cycle, contraception (including a coil), sexual history
- Vaginal bleeding or discharge
- A previous ectopic pregnancy, pelvic infection, tubal surgery or fertility treatment
- Urinary and bowel symptoms, fever
- The shoulder pain: when it started, worse lying flat

## Red flags

- Fainting, a fast pulse, low blood pressure, pallor
- Shoulder-tip pain
- Guarding, rigidity or a swollen abdomen
- Heavy vaginal bleeding
- A positive pregnancy test with pain

## What to examine

- Airway, breathing, circulation: pulse, blood pressure, capillary refill
- Abdomen: tenderness, guarding, rebound, swelling
- Pelvic examination by the right clinician with a chaperone: cervical motion tenderness, adnexal tenderness or mass, bleeding
- Temperature

## First investigations

- Urine or blood pregnancy test at once
- Full blood count, blood group and crossmatch, clotting
- Bedside ultrasound for free fluid in the abdomen
- Transvaginal ultrasound
- Quantitative serum hCG
- Urine dipstick and culture, CRP

## Differential diagnosis of lower abdominal pain with collapse in a young woman

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

### Surgical

- Appendicitis
- Perforation

### Ovary and tubes

- Ruptured or bleeding ovarian cyst
- Ovarian torsion
- Pelvic inflammatory disease

### Pregnancy-related

- Ectopic pregnancy
- Miscarriage

### Urinary

- Kidney or ureteric stone
- Kidney infection

### Other

- A simple faint, only once the others are excluded

## Common mistakes

- Not doing a pregnancy test because she says she cannot be pregnant.
- Being reassured by a normal first haemoglobin: it can be normal early in acute bleeding.
- Sending an unstable patient away for imaging instead of calling the gynaecology team and theatre early.

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A study guide for medical students, not medical advice. Follow your institution's protocols in practice.