Differential Diagnosis for Severe Lower Abdominal Pain in a 42-year-old Woman
- Single most likely diagnosis:
- Adenomyosis with degeneration or rupture: The patient's history of adenomyosis, recent onset of menses, and the description of the uterus as globular and boggy support this diagnosis. The severe pain radiating to the left lower quadrant and the presence of dark red blood with small clots in the vagina also align with adenomyosis complications.
- Other Likely diagnoses:
- Ovarian cyst rupture or torsion: The tenderness in the left adnexa and the acute onset of severe pain could suggest an ovarian cyst complication, despite the absence of a palpable adnexal mass.
- Endometriosis: Given the patient's history of heavy menses and dysmenorrhea, endometriosis could be a contributing factor to her current pain, especially if there are endometriotic implants in the left lower quadrant.
- Pelvic inflammatory disease (PID): Although the patient does not have fever or abnormal vaginal discharge, PID cannot be entirely ruled out without further testing, especially if there's a possibility of silent or atypical presentation.
- Do Not Miss diagnoses:
- Ectopic pregnancy: Despite a negative urine pregnancy test, ectopic pregnancy must be considered in any woman of childbearing age presenting with severe lower abdominal pain, especially if there's any chance the pregnancy test could be false negative.
- Ruptured appendix: Appendicitis can present with pain in the lower quadrants and must be considered, even though the abdomen is described as soft and there are normoactive bowel sounds.
- Ovarian tumor with rupture or torsion: A tumor could cause severe pain and potentially life-threatening complications if ruptured or torsioned.
- Rare diagnoses:
- Uterine rupture: Although rare, especially in a non-pregnant woman, uterine rupture could occur in the context of adenomyosis, particularly if there's a significant degeneration or if the patient has undergone previous uterine surgery.
- Hemorrhagic corpus luteum cyst: This condition could cause acute pain and bleeding, although it's less likely given the patient's presentation and the absence of a palpable adnexal mass.