31 y/o female presents with chief complaint of right groin pain which extends to midline pelvis down to inner thigh. Symptoms are generally mild until patient drives, sits, or stands 30 minutes or longer. Patient states onset has been about 3 months ago and is now progressively getting worse. No trauma or injury noted by patient. Pain is better when patient lays down on other hip, but does not completely diminish.

Patient past surgical history: Complete hysterectomy, appendectomy, cholecystectomy

Patient medical history: mild Fibromyalgia, chronic sinusitis, appendicitis, Gall bladder EF=14%, "malfunctioning uterus", superficial blood clot (pregnancy)

Patient family medical history: Cancer (bone, blood, lung, kidney, breast), Heart attack, DVT’s, anemia, HTN, hernia

1st office visit: Dr. ordered venous duplex and x-ray of right hip after ruling out hernia.

After both tests came back normal, Dr. ordered CT scan with contrast of abdomen/pelvis…results were pseudo finding of transverse ascending colon inflammation consistent with colitis.

After reviewing results of CT, physician had patient trial an oral steroid (Medrol Dose Pack) Patient’s symptoms became intensley worse on this medication. Initially, the upper groin/pelvic pain got better, but entire right hip "was on fire" where the patient stated that she couldn’t even stand having anything touch it including her underwear. As the medication gradually decreased the original symptoms returned at a gradual pace and the "fire" in her hip lessened as the medication dosage lessened.

2nd office visit: Due to the worsening effect from the Medrol, physician did pelvic exam and noted severe bone pain located at the top right of patients vaginal wall. Patient stated that there has been a dull ache there at all times since Feb 2009 and was made worse with sexual intercourse but hadn’t thought of that earlier. (no history of STD’s)

Pysician ordered full pelvic x-ray, basic lab workup, and MRI’s of hip and pelvis…all were negative.

Patient was sent to have a nerve conduction test and EMG…both negative.

Patient’s pain is presently worsening and she is now unable to drive longer than 10 minutes if pain was previously aggrivated and 20 minutes if not. Dull pain is continuously present but is made excrutiating when putting pressure on the pelvic bone itself. Pain seems to be worst in groin, vaginal, and bottom of the buttocks areas.

Things ruled out already: DVT, Hernia, bone infection, visible tumor, nerve entrapment, spinal and/or disc problems, arthritis, and referred pain

Does anyone have any suggestions as to what this odd presentation of symptoms could be? How about a next step suggestion? We are running out of options and we are 100% positive this is not "in the patient’s head". Any further insight and ideas are greatly appreciated! Thanks.
Pt is 5’3" and 134 lbs and has also had complaints of fatigue for about 1 year.
Thanks Douglas, for your input. Unfortunately, this does not seem to be the issue. Was a great idea though!
Thank you Kathy. However, the oral steroid (Medrol) that was tried should have helped the pain if this was the issue. This medication is an oral substitue to a corticosteroid that is injected to relieve this type of nerve pain that isn’t fixed with manipulation. Therefore, the pt’s poor response to the Medrol trial would rule this out. Thanks again…was an interesting and great find!

A 57-year-old male was admitted to our hospital on May 4th ,2007 for abdominal pain for four weeks accompanied with emesia and diarrhea. The clinical findings are listed in Table 1.
Past medical history and general state of health:
The patient’s past medical history was significant for spinal stenosis about two years ago, accompanied with the symmetry pain of limbs arthrosis for one year. He denied other systemic diseases and any surgical history, as well as family history of genetic disorder. Before the onset of the disease ,the patient had the history of exposure to a small amount of acetone(He is a aircraft mechanic). He denied the history of exposure to special food ,drug and toxicant.
Since the pathogenesis , the patient has no fever and night sweat, no skin petechia and skin rashes .There is a 2.5 kg weight loss recently.
Medical examination:
Left lower quadrant and superior belly had scattered tendernesses, no rebound tenderness. Other examinations were negative.
Table 1 Clinical manifestations of the patient:
Main clinical manifestations abdominal pain : Started left lower abdomen pain ,and then emerging superior belly pain, accompanied with nausea
frequent emesia : Vomiting after eating a little food, and Vomitus were a small amount of stomach contents
chronic diarrhea : watery stool, and there were no mucus ,pus and blood in the stool. More than 10 times a day ,and the quantity of toties quoties was 50-100ml.
Laboratory positive findingsBlood routine—WBCC:7.8*109/L, Lymphocyte Percentage:10%, neutrophils Percentage:84.5%, Eosinophil count:0.6*109/L;
Albumin: 31-33g/L, prealbumin:142mg/L; blood calcium: 1.97-2.02mmol/L , blood phosphonium: 0.80-0.97mmol/L ,PTH:174ng/L, Calcitionin:3.4ng/L ;
blood sedimentation: 24mm/h, Ferritin: 924.9ng/mL;
Anti-SS-A:+, ANA:+++, Alexine C3:0.77g/L,CRP 36.6mg/L ; Serum transferrin: 1.97g/L;
Urine protein:+, Quantitation of Urine protein in 24h: Microamount albumen 196mg/L, Transferrin 11.1mg/L, Microglobulin 41.2 mg/L , IgG 31.3mg/L. Stool smear:a little Capsule protozoon；
Endoscopy findingsColoscope showed that mucous membranes of colon and rectum had extensive dropsy, as well as rectal scattered anabrosis.
Gastroscope showed superficial gastritis , accompanied with anabrosis.
Image findingsComputer tomography (CT) of epigastric zone showing edema of gastric wall and duodenal wall, right pleural effusion, seroperitoneum and bilateral hydronephrosis ;
Computer tomography (CT) of hypogastric zone showing thickening and edema of the part small intestine, ascending colon, sigmoid colon and rectum, furthermore , abnormal thickening of Bladder wall left; Computer tomography (CT) of chest showing right pleural effusion;
B ultrasonic of glandula thyreoidea showing a mixed tumor and a solid tumor on the right, furthermore ,a left thyroid nodules .
MRI of glandula thyreoidea showing multiple innocuousness nodules in right thyroid
ECT of epithelial body showing no obviously abnormal.

Pathological findingsRectal chronic inflammation

Other examinations (such as stool routine , stool culture ,tuberculin test, hepar and renal function, thyroid function, tumor markers, prothrombin time, HIV TPPA TRUST ,rheumatoid factor, anti-O, IgA E G M, C4 CH50 CIC, dsDNA anti-SS-B anti-SM, ACLA ,ANCA and B ultrasonic of the heart) were all negative.
To the treat and turnover:
After admission, we gave the patient the treatment of restrain acidum （Losec）, anti-inflammatory（Ceftriaxone and metronidazole）and nutritional support. But the patient’s pathogenetic condition didn’t take a favorable turn. Since May 10th , we have given the patient hormone therapy—300mg hydrocortisone iv gtt qd. Currently , the patient still has abdominal pain and diarrhea.
To request:
1. to diagnose: about the etiological factor and etiopathogenisis
2.to treat: such as some better therapeutic regimens and some precious clinic experience