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Family Medicine 20 28-year-old female with lowerabdominal p
1. Family Medicine 20: 28-year-old female with lower
abdominal pain
User: Daniela Fernandez
Email: [email protected]
Date: February 24, 2021 11:32PM
Learning Objectives
The student should be able to:
Conduct a culturally sensitive, empathic history.
Appreciate the ways in which victims of violence may manifest
symptoms and be alert to clues a patient may give that he/she
has been a victim of intimate partner violence.
Discuss ways to assist the patient in developing a safety plan.
Discuss reporting requirements for intimate partner violence.
Appreciate a survivor’s perspective in an abusive relationship
and the barriers to his/her seeking help.
Apply knowledge of the differential diagnosis of lower
abdominal and pelvic pain in evaluating the patient.
Knowledge
Significance of the Location of Lower Abdominal Pain
The location of the abdominal pain is important, as it can help
narrow your differential diagnosis. For example, diffuse
abdominal
pain may represent gastroenteritis, whereas localized right
lower quadrant pain is classic for but not limited to
appendicitis. Think
about what is in the various quadrants of the abdomen when
2. considering the differential diagnosis of abdominal pain.
Red Flags of Life-Threatening Condition in Patient with Lower
Abdominal/Pelvic Pain
There are many signs and symptoms of a life-threatening
condition in a patient with abdominal or pelvic pain. Examples
include:
Abrupt onset of severe pain
Shock with hypotension and tachycardia
Distension
Peritoneal irritation signs
Rigid abdomen
Pulsatile abdominal mass
Absent bowel sounds
Fever
Vomiting
Diarrhea
Weight loss
Menstrual changes
Trauma, prior surgeries, or operative scars
History/presence of blood in emesis
History/presence of blood in stool
Severity of the pain
Ecchymoses/bruising
Rebound tenderness
Mass or ascites
Obstetrical History
G Gravida or number of pregnancies
T Number of Term pregnancies
P Number of Preterm infants
4. Constipation: Patients may give a history of having small, hard
pellets for stools, decreased frequency of stooling, harder stools
than usual, or occasionally having loose stools, which may
actually signify an impaction, where the patient has soft stool
leaking
around an impacted hard stool. This type of stooling pattern is
more often associated with irritable bowel syndrome.
Irritable bowel syndrome (IBS): Many patients will describe
abdominal pains of varying location, associated with either soft,
frequent, loose stools, or constipation, or an alternating stool
pattern. They may also describe abdominal bloating, increased
flatulence, and mucus in the stool. The symptoms of IBS are
frequently worse when the patient is under stress, anxious, or
depressed. Symptoms of IBS can be brought on initially by a
case of gastroenteritis and can be aggravated by stress, diet, and
change in activity—and the symptoms are often unpredictable.
Caffeine and dairy products can make symptoms worse. The
diagnosis is based on clinical history, physical exam, and
absence of alarming symptoms suggesting other pathology.
The Rome IV criteria is often used to aid diagnosis of adult
IBS:
Recurrent abdominal pain, on average ≥ 1 day per week in past
3 months with two or more of following features:
1. Related to defecation
2. Associated with change in stool frequency
3. Associated with change in stool form (appearance)
Endometriosis: Patients with endometriosis may begin to notice
increasingly more painful and heavier menstrual cycles as early
as late adolescence. A patient with endometriosis might indeed
have lower abdominal discomfort, often starting after ovulation
during most cycles and continuing through their menstrual
cycle. There may also be low back pain or painful stooling. It is
not
5. uncommon for a patient with endometriosis to experience pain
with intercourse. Ultrasounds or MRIs may be needed in order
to
help diagnose the problem. Laparoscopy may be needed to
definitively diagnose, treat, or alleviate symptoms. Hormonal
contraception often stops the pain and the process, thus
preserving the patient’s ability to become pregnant later.
Genetic factors
are often involved.
Inflammatory bowel disease (IBD): Patients with IBD usually
have some combination of abdominal pain, bloody diarrhea, and
frequent stooling. The onset of symptoms frequently occurs in
the late 20s or early 30s. The patient may ultimately be
diagnosed
with either ulcerative colitis or Crohn Disease. Diagnosis is
made through specific radiological findings on barium enema,
small
bowel follow-through, and by colonoscopy.
Muscular pain or musculoskeletal pain is generally
reproducible. On exam, there is usually point tenderness to
palpation of
the affected muscles. The pain may recur during certain
activities or when the offending position is (re)assumed.
Psychosomatic pain: Symptoms from this type of pain are
variable and can be associated with or aggravated by other
etiologies
such as IBS or gastritis. The pains can occur anywhere
throughout the abdomen. They usually present as an atypical
pain pattern,
occur in a depressed or otherwise mentally ill patient, and may
point toward a psychogenic cause. This is a diagnosis of
exclusion.
Stress: The patient's symptoms and pains tend to be increased
when the patient is under increased stress or is involved in other
negative interactions. The patient may present with a whole
constellation of other stress-related symptoms, such as
7. Screening recommendations:
The American College of Obstetrics and Gynecology suggests
screening all patients who come to them (family planning
patients,
all ob-gyn patients, and all prenatal patients) at first visit, at
each trimester, and at the postpartum visit. It may help to
preface
asking such questions with a statement such as: "Because
intimate partner violence (IPV) is so common, I ask all of my
patients
about this..."
The U.S. Preventive Services Task Force (USPSTF)
recommends that clinicians screen women of childbearing age
for IPV, such as
domestic violence, and provide or refer women who screen
positive to intervention services. (Level of Evidence: B)
This is routinely done at annual exams or when red flags are
present.
Here is a good resource regarding screening for intimate partner
violence.
Prevalence:
It is important to be aware of IPV when addressing our patients,
as approximately 25% of women in the U.S. report being
victimized by an intimate partner at some point in their lifetime.
While the majority of IPV victims are women, they can be any
gender, occur in both heterosexual and same-sex relationships,
and across all socioeconomic, age, and ethnic divides.
Complications:
In addition to the trauma incurred, the rates of chronic
disease—including heart disease, diabetes, depression, and
suicide—are
significantly higher in victims as well as in adults who were
8. victimized as children as a result of direct abuse and exposure
to IPV.
Symptoms and Conditions Experienced More Frequently by
Victims of IPV Red Flags for Intimate
Partner Violence
Individuals who were victimized by their intimate partner are
more likely to experience:
Migraines, frequent headaches
Chronic pain syndrome
Heart and blood pressure problems
Arthritis
Stomach ulcers, frequent indigestion, diarrhea, constipation,
irritable bowel syndrome, spastic colon
Pain during sex (dyspareunia), dysmenorrhea, vaginitis, pelvic
inflammatory disease, chronic pelvic pain syndrome, and
other gynecological diagnoses
Invasive cervical cancer and preinvasive cervical neoplasia
Depression, anxiety, and post-traumatic stress
Unexplained or poorly explained findings on physical exam
Red flags for intimate partner violence include:
Delay in seeking medical care
Non-compliance with treatment plan
Partner insisting on staying close and answering questions
directed to patient
Hesitancy or not answering questions or inconsistent or
incorrect answers given to questions
Shyness or reticence in answering questions
Explanation of problem or incident does not match severity of
findings
Facilitating Discussion About Intimate Partner Violence
9. There are several nonjudgmental ways to ask about intimate
partner violence. Examples include:
"Do you feel safe at home?"
"Because violence is so common, and there are so many forms
of violence, I am asking all my patients about it. Is anyone
now or has anyone in the past hurt you emotionally, physically,
or sexually. Is anyone threatening you?"
"All couples disagree at sometime. What happens when you
disagree/fight/argue?"
"Does your partner ever force you to do things you do not want
to do or keep you from doing things you want to do?"
"How do you handle money issues in your relationship?"
"I often see the type of symptoms that you have in people who
are being hurt at home or in a relationship. Do you think that
this might be happening to you?"
There are lots of things you can do to facilitate discussion about
IPV.
Ask screening
questions
Many clinics will ask a screening question of all patients during
the triage process. Asking the patient, "Do you
feel safe at home?" follows the vital signs and questions about
whether or not the patient is having any pain.
This open-ended question allows the patient to share
information they might have about feeling unsafe at
home, in their neighborhood, or where they live, work, or shop,
or feeling threatened or actually being abused
by someone. This question is appropriate for any age, gender, or
socioeconomic class. It may take several
visits for the patient to feel comfortable enough with the
provider to discuss such a sensitive issue.
11. Ensure
confidentiality
Update and review HIPAA forms and make sure that all staff
are aware of how to use them. Be sure to tell the
patient that anything discussed in the room will not be shared
with anyone not directly involved with their
care, including their partner and family members.
Direct
assessment
Interviewing can begin with indirect questions such as, "Tell me
about your relationship," but should include a
direct assessment of safety, including questions regarding
weapons in the house and danger or possible harm
to the children or pets.
Know your local
laws
All states require reporting of child abuse and some require
reporting of intimate partner violence. Be open
with your patient about your legal constraints.
Facilitate
impartiality
Consider using a telephone service for interpretation if an
appropriate professional interpreter is not present in
the office. Do not use a friend or relative.
Listen
nonjudgmentally Validate the patient's concerns and the fact
that abuse is not the fault of the victim.
12. Handling Children During a Sensitive History and Exam
It is generally preferred to have children outside the room
during a pelvic or genital exam of the parent. Depending on the
age of
the child, some parents may prefer to have the child sit in the
room in a corner and face away from the exam table, or keep a
sleeping child in a stroller in the room with them. The clinician
may have sensitive questions to ask; the parent-patient may not
want the child to see them undressed and undergoing this exam.
There is frequently someone on staff who will watch or
entertain the child or children during this portion of the exam.
Or the
parent may have come to the clinic with a friend or relative with
whom the child can stay in the waiting room during that portion
of the visit.
It is also important to have a chaperone in the room for the
exam for legal reasons and for protection of the clinical staff.
This
person should be named in the chart note.
Symptoms of Exposure to Domestic Violence in Children and
Adolescents
Obvious physical signs of physical or sexual abuse
Behavioral or emotional problems, such as increased
aggression, increased fear or anxiety, difficulty sleeping or
eating, or
other signs of emotional distress
Chronic somatic concerns
30% to 60% of perpetrators of intimate partner violence also
abuse children in the household.
Intimate Partner Violence Safety Assessment
14. affectionate. Unfortunately, in most cases, the cycle begins
again and often the violence is increasingly severe.
Documenting a Case of Suspected Intimate Partner Violence
When documenting a history of abusive behavior, use the
patient's own words in quotes and fill in names after pronouns
are used.
Example: "then he (John Smith)…". Use neutral language.
Example: "patient states", not "patient alleges," which may give
a false
impression of disbelief.
Give a detailed description of the patient's appearance,
behavioral indicators, injuries and stages of healing, and health
conditions. If the patient consents, use photos to document
injuries; one with a face included in the photo, and then close-
ups of
the injury. If photos are not possible, draw and describe injuries
on a body map in blue ink as this is difficult to alter/reproduce.
Document recommendations for support and follow-up as well
as materials given to the patient.
Document abuse history as reported by patient in the subjective.
The subjective section is meant to document the patient's
experience and verification is not applicable. Include any
laboratory and radiology tests ordered with results to maintain a
complete record for the patient. Document results of health and
safety assessments and plans for follow-up as well as referrals
and materials given to the patient. Document recommendations
for support. If the patient was referred for a post-rape exam,
document the referral site. Maintain strict confidentiality and
safeguard the chart rather than limit the contents for best care
practices.
Clinical Skills
Adequately Addressing Your Patient's Needs Within Time
15. Constraints
It is a common scenario to see a patient that is scheduled for an
acute visit, but the situation requires more time to be adequately
addressed. Prioritize the most acute or high risk issues raised
during this visit and focus on these, and then emphasize the
importance of follow-up and schedule a follow-up visit as soon
as possible.
Management
The Role of the Health Care Provider in the Care of a Victim of
Intimate Partner Violence
Acknowledge
the abuse
and health
implications
It is important to acknowledge the abuse, recognize the health
implications, and share this with your patient.
Support your
patient's
decisions
While you may not always agree with the decisions your patient
makes to stay or escape, it is important that you
support their decisions. They have a greater understanding of
the complexity of the problem, and have more
information on which to base their actions.
Address
safety issues
Address the level of risk and safety issues for your patient.
16. Provide information for them to go to a safe haven if
needed. As lack of a telephone or computer (or monitoring of
their use) often make it unsafe or impossible for
victims to contact IPV resources from home, it is important not
only to give contact information to the patient, but
also to offer a means for them to contact services while in your
office. One should be aware that the person inflicting
the violence might check the patient's/victim's phone and
computer for recent phone calls, website visits, and
emails.
Practice
cultural
sensitivity
Cultural differences can give the appearance of abuse, be
accepting of practices some might consider abusive, and
can inhibit the ability to interview or support a victim.
Practicing sensitivity in caring for patients from different
backgrounds is key to a supportive patient-clinician
relationship.
Consider
impact of
abuse on
children and
other
vulnerable
When children or other vulnerable persons who are less able to
make decisions on their own behalf are in the home,
consideration must be given to the impact of the abuse on them
physically and mentally as well as their safety.
Even in states where reporting abuse towards a domestic partner
is not mandated, the impact or abuse on a child or
other vulnerable person may be and will supersede the desires
18. report this abuse to
child protection services. Mandated reporters would also report
any high-risk situation of IPV in which children are at risk.
However, state laws are less clear about whether exposure to
IPV in the absence of injury or serious risk of injury to the
child
would require a report to children's protective services.
In some states, stringent rules/laws require mandated reporters
to notify child protection services whenever a child is in the
home
and has been exposed to a parent's abuse, whether or not the
child has been directly abused. Proponents of this definition
point to
the ample documentation of the overlap between adult IPV and
child abuse and the adverse psychological effects on children
who
witness IPV. Opponents of this policy believe it penalizes
women for abuse that they have no control over and may
discourage
women from seeking help. It also could elevate the level of risk
for the victim.
In other states, a child's exposure to IPV does not automatically
require a mandatory child protection report. The provider has
wider discretion to assess whether a child has been directly
involved and what other factors may exist to put the child at
risk. In
these states, a provider would take into account the existence of
direct injury to a child, the potential danger of the situation, and
the capacity of the mother to keep her children safe in deciding
whether to notify Child Protective Services (CPS).
The rules for victims who are adults and are not disabled vary
dramatically from state to state, from mandatory reporting for
evidence of abuse to reporting only if the victim asks the
clinician to do so. Contact your local Domestic Violence
helpline and ask
what the rules are for the community in which you work. You
19. can find out about your local resources by calling the National
DV
Hotline at (800) 799-SAFE, TTY (800) 787-3224.
Studies
Recommended Studies for Evaluation of Lower Abdominal Pai n
Pap test—
thin prep Recommended in the setting of previous abnormal
results.
KOH/saline
wet prep
This is a quick test which should be done as it could indicate
inflammation (white blood cells) or diagnose
trichomonas, bacterial vaginosis, or yeast vaginitis.
Chlamydia /
gonorrhea
DNA probe
Chlamydia and gonorrhea can present with a yellow discharge,
abdominal pain, and dyspareunia. This is the
preferred method for diagnosis of chlamydia and gonorrhea
because both can be performed using the same
sample, and the sample can be endocervical, urethral, vaginal,
oral, or urine.
Urine
dipstick Helpful to rule out a urinary tract infection (UTI).
Urine
pregnancy
test
21. this is still the preferred method for sexual assault tests, for
tests of cure, and for oral and rectal specimen.
HCG beta sub This is generally not indicated because of the
sensitivity of the urine pregnancy test. If the results of the
urinepregnancy test were inconclusive, a blood test such as
HCG Beta Sub would be needed.
Clinical Reasoning
Severe / Life-Threatening Causes of Abdominal Pain
Appendicitis
Patients with appendicitis often start with visceral pain that is
dull and in the periumbilical region; within a short
time the pain classically localizes; presentation is usually of
fairly acute onset with moderate to severe right
lower quadrant pain. There is often a history of nausea and/or
vomiting. There are usually some changes in the
patient's bowel movements.
Ectopic
pregnancy
Ectopic pregnancy is a medical emergency. Early medical
treatment reduces the need for surgery, but if the
fallopian tube is in danger of rupture, surgical intervention may
be necessary. Patients present with divergent
symptoms ranging from no pain and normal menses to intense
pain and irregular or absent menses. A good
history, the physical exam and lab testing (always get a
pregnancy test if the patient has a uterus) are crucial for
this diagnosis. Imaging is also usually needed. You need the
date of the patient's last menstrual period (LMP), her
menstrual history, most recent intercourse dates, the types of
contraception used currently and used in the past
22. /ever used, history of any vaginal or pelvic infections, and
history of previous ectopic or normal pregnancies.
Endometriosis
While endometriosis is not typically life-threatening, it can be
severe. The majority of patients are of reproductive
age and present with cyclical pelvic pain, following the
menstrual cycle in patients with regular menses. The
location and pattern of the pain can vary widely, depending
upon which organs have been affected. For example,
those with bladder involvement may present with urinary
frequency, urgency or dysuria. Endometriosis may also
present as infertility in an otherwise asymptomatic patient or as
an incidental finding during surgery.
Ovarian
pathology
Patients with ovarian problems generally have lower abdominal
or pelvic pain. Pain from ovarian torsion or
ruptured cyst or ectopic pregnancy may be very severe and
usually has a sudden onset. Patients often present to
the emergency department due to the pain, and this is
appropriate since imaging is usually necessary to
determine the exact cause of the pain. In several cases, the pain
from ovarian problems may persist for several
weeks. It is often aggravated by intercourse or strenuous
activity.
Pelvic
inflammatory
disease
Patients with pelvic inflammatory disease (PID) might have
abdominal or pelvic pain, which is worse with sexual
23. intercourse or with activities such as running or jumping, which
cause jarring of the pelvic organs. This diagnosis
has significant morbidity, which increases with the severity of
the disease and with the length of time to
diagnosis. Studies show that approximately one in four patients
who had a single episode of PID later
experienced tubal infertility, chronic pelvic pain, or an ectopic
pregnancy, as a result of scarring and adhesions.
Tubal adhesions leading to infertility have been reported to
occur in 33% of patients after their first episode of
PID, and up to 50% after the second pelvic infection.
Normal
pregnancy
Patients who have normal pregnancies may experience some
lower abdominal discomfort or pain as the uterus
undergoes normal growth. This is more a diagnosis of
exclusion, but you would not want to miss a pregnancy.
Certain medications should not be given to patients who are
pregnant. Fetuses should not be exposed to
radiation.
Trauma
A careful history is important in regard to trauma. Be aware of
the patient's body language and response to
touch. Consider the consistency of the history with the exam.
Have the patient undress and examine the patient
thoroughly in a gown so that all areas can be visualized.
Consider taking a photograph of any injuries and bruises
if there is a way to appropriately attach them to the patient's
medical record, and if the patient gives consent.
References
American College of Obstetricians and Gynecologists (ACOG).
25. Family Violence Prevention Fund. Compendium of State
Statutes and Policies on Domestic Violence and Health Care.
Produced 2010.
Accessed June 9, 2020.
Futures Without Violence (formerly The Family Violence
Prevention Fund). First Printing: September, 2002. Updated:
2020. Accessed
February 8, 2020.
Futures Without Violence. The Facts on Domestic, Dating and
Sexual Violence. Released 2009. Accessed February 8, 2020.
Futures Without Violence. The Facts on Women, Children and
Gun Violence. Released 2013. Accessed February 8, 2020.
Futures Without Violence. The Health Care Costs of Domestic
and Sexual Violence. Updated March 2010. Accessed February
8, 2020.
Hatcher RA et al. Contraceptive Technology 19th edition,
Ardent Media, 2007.
http://www.contraceptivetechnology.org/table.html.
Accessed February 8, 2020.
Institute for Clinical Systems Improvement (ICSI). Initial
management of abnormal cervical cytology (Pap smear) and
HPV testing.
Algorithm. Bloomington (MN): Institute for Clinical Systems
Improvement (ICSI); Oct 2008;32:63. Accessed February 8,
2020.
Katz VL et al, Infections of the Upper Genital Tract:
Endometritis, Acute and Chronic Salpingitis In: Comprehensive
Gynecology, 5th
edition. Philadelphia, PA: Mosby; 2007.
26. Marsicano E, Vuong GM, Prather CM. Gastrointestinal causes
of abdominal pain. Obstet Gynecol Clin North Am.
2014;41(3):465-89.
National Consensus Guidelines on Identifying and Responding
to Domestic Violence Victimization in Health Care Settings.
Produced by
The Family Violence Prevention Fund, 383 Rhode Island Street,
Suite 304, San Francisco, CA 94103-5133. (415) 252-8900.
TTY (800)
595-4889. First Printing: September, 2002. Updated: February,
2004.
Planned Parenthood Interactive website. Birth Control Methods
and Options | Types of Birth Control. Accessed February 8,
2020.
Shian B, Larson ST. Abdominal Wall Pain: Clinical Evaluation,
Differential Diagnosis, and Treatment. Am Fam Physician.
2018;98(7):429-36.
Silverman JG, Decker MR, Reed E, Raj A. Intimate partner
violence victimization prior to and during pregnancy among
women residing
in 26 U.S. states: associations with maternal and neonatal
health. Am J Obstet Gynecol. 2006;195(1):140‐ 8.
Trigg BG, Kerndt PR, Aynalem G. Sexually transmitted
infections and pelvic inflammatory disease in women. Med Clin
North Am.
2008;92(5):1083‐ 113.
Wet Mount. Military Obstetricts & Gynecology.
http://www.brooksidepress.org/Products/Military_OBGYN/Text
book/Discharge/WetMount.htm Accessed June 9, 2020.
28. Pain HistorySome Common Causes of Lower Abdominal Pain
Presenting in Primary CareIntimate Partner Violence: Screening
Recommendations, Prevalence, and ComplicationsSymptoms
and Conditions Experienced More Frequently by Victims of IPV
Red Flags for Intimate Partner ViolenceFacilitating Discussion
About Intimate Partner ViolenceHandling Children During a
Sensitive History and ExamSymptoms of Exposure to Domestic
Violence in Children and AdolescentsIntimate Partner Violence
Safety AssessmentIncreasing Severity of Intimate Partner
ViolenceEscalating Cycle of Intimate Partner
ViolenceDocumenting a Case of Suspected Intimate Partner
ViolenceClinical SkillsAdequately Addressing Your Patient's
Needs Within Time ConstraintsManagementThe Role of the
Health Care Provider in the Care of a Victim of Intimate Partner
ViolenceStudiesRecommended Studies for Evaluation of Lower
Abdominal PainClinical ReasoningSevere / Life-Threatening
Causes of Abdominal PainReferences
Assignment requirements
Read “Case 6: Fixer Upper: Expanding the Magnolia Brand” in
your Connect textbook.
Evaluate Magnolia Brands’ sustainable competitive advantage
by analyzing the case study and answering the following
questions in 350 to 525 words:
· How will the components of the external environment impact
Magnolia Brands’ ability to realize their vision?
· Who are Magnolia Brands’ major competitors?
· What other factors are affecting the growth of Magnolia
Brands?
· What internal factors must be considered for Magnolia Brands
to achieve its vision and mission?
· What are some of Magnolia Brands’ strengths and
weaknesses?
· How does the new show represent an opportunity in the home
29. remodeling industry?
· What challenges or threats might Magnolia Brand face?
· What measurements can be used to determine if the new show
is successful?
· What is the feasibility of the ability of Magnolia Brands to
continue to be successful? Why?
Read Case 8.3: Speaking Out about Malt, located on page 311 in
your textbook. Determine whether Mary acted irresponsibly or
disloyally in your opinion. Describe the actions that you think
Mary should take next. Explain what you would do if you were
in Mary’s position.
![Family Medicine 20: 28-year-old female with lower
abdominal pain
User: Daniela Fernandez
Email: [email protected]
Date: February 24, 2021 11:32PM
Learning Objectives
The student should be able to:
Conduct a culturally sensitive, empathic history.
Appreciate the ways in which victims of violence may manifest
symptoms and be alert to clues a patient may give that he/she
has been a victim of intimate partner violence.
Discuss ways to assist the patient in developing a safety plan.
Discuss reporting requirements for intimate partner violence.
Appreciate a survivor’s perspective in an abusive relationship
and the barriers to his/her seeking help.
Apply knowledge of the differential diagnosis of lower
abdominal and pelvic pain in evaluating the patient.
Knowledge
Significance of the Location of Lower Abdominal Pain
The location of the abdominal pain is important, as it can help
narrow your differential diagnosis. For example, diffuse
abdominal
pain may represent gastroenteritis, whereas localized right
lower quadrant pain is classic for but not limited to
appendicitis. Think
about what is in the various quadrants of the abdomen when](https://image.slidesharecdn.com/familymedicine2028-year-oldfemalewithlowerabdominalp-220921012547-2a4c93bd/85/Family-Medicine-20-28-year-old-female-with-lowerabdominal-p-1-320.jpg)
