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.
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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.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: Kazuki Iio, MD, Division of Pediatric Emergency Medicine, Tokyo Metropolitan Children’s Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo 183-8561, Japan (firstname.lastname@example.org).
Published Online: November 28, 2022. doi:10.1001/jama.2022.20402
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank James R. Valera, MA (Tokyo Metropolitan Government), for his assistance with editing this manuscript. Mr Valera was compensated for his contributions. We also thank the patient’s mother for providing permission to share the patient’s information.
Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:
It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.
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