A 15-year-old adolescent girl who was taking an oral contraceptive presented to the emergency department with left lower quadrant abdominal pain that had developed gradually over a 3-day period. She had no associated nausea, vomiting, diarrhea, hematochezia, bloating, or anorexia. She reported no precipitating factors for the pain and had no history of pregnancy, abdominal surgery, or abdominal trauma. Over the previous 2 years, the patient had experienced similar intermittent episodes of abdominal pain lasting approximately 1 week. Results from laboratory tests, upper endoscopy, colonoscopy, and an abdominal computed tomography scan performed 1 year prior to presentation were normal.
In the emergency department, her vital signs were normal and her body mass index was 20.4 (calculated as weight in kilograms divided by the square of height in meters). Abdominal examination revealed no rigidity or guarding; however, a 1-cm point of maximal tenderness was identified in the left lower abdominal quadrant (Figure). During palpation of this 1-cm area, the pain increased when she lifted her head and tensed her abdominal muscles. She experienced cold hypoesthesia when an alcohol gauze pad was applied to this area and severe pain when the skin was pinched.