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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Anterior cutaneous nerve entrapment syndrome (ACNES)
C. Inject a local anesthetic into the area of maximal tenderness
The key to the correct diagnosis was recognition that the 1-cm point of maximal tenderness was localized to the outer rim of the rectus abdominis muscle.1 Gabapentin (choice A) is not recommended because the diagnosis of postherpetic neuralgia is unlikely without a rash or dermatomal distribution of abdominal pain. Choice B is incorrect because the abdominal pain caused by celiac artery compression syndrome is typically epigastric and often increases after eating. Measuring urine porphobilinogen level (choice D) is unnecessary because acute intermittent porphyria typically causes diffuse abdominal pain.
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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 (email@example.com).
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.
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