Time & Date:
ID: Name, age
CC: pelvic pain
HPI:
- Onset – acute vs. chronic, recurrent or not recurrent with menses (sudden onset – torsion)
- Location – unilateral vs. bilateral (PID – bilateral; ectopic, torsion, rupture – unilateral)
- Duration – acute vs. chronic
- Provoking/ Alleviating factors
- Quality – (dysmenorrhea – cramping; fibroid – ache; rupture – sharp pain)
- Radiation – (uterus/Cx/vagina – low back & buttocks; ovaries/tubes – medial aspect of thigh; endometriosis – rectum/perineum)
- Severity – (torsion – SEVERE pain)
- Associated Symptoms:
- arthralgia (PID)
- fever (PID, rupture)
- N/V (torsion, PID), diarrhea, constipation
- dysuria (fibroid)
- dyspareunia (fibroid)
- d/c – (PID)
- vaginal bleeding (fibroid, PID)
- Timing – association with menses
MEDs:
ALLERGIES:
Menstrual history:
- LMP (missed menses 1-2 wks – ectopic)
- recurrent spotting
- menorrhagia
GyneHx:
- PID
POBHx:
- previous ectopics
- infertility
Sexual Hx:
- contraception, IUD (past use increases risk of ectopics)
- STDs
- dyspareunia
PMHx:
PSurgHx:
- surgeries on tubes
- laparoscopy/ laparotomy
- pelvic surgery
PE: Say you “would do a full physical, focusing on the abdomen & pelvis”
Differential Dx of acute pelvic pain: ectopic, torsion, rupture, PID, extrapelvic (e.g. appendicitis)
Differential Dx of chronic pelvic pain recurrent with menses: dysmenorrhea, desmenorrhea (endometriosis, adenomyosis, chronic PID, assoc’d IUD)
Differential Dx of chronic pelvic pain recurrent but not assoc’d with menses: mittelschmerz, IBD, IBS
Differential Dx of non-recurrent chronic pelvic pain: neoplasm, non-gyne, enigmatic or psychogenic
PID – usually chlamydia or gonorrhea
– to dx, need: lower abdo pain, tenderness on exam, cervical motion tenderness, adnexal tenderness AND one or more of: fever, d/c, lab evidence of STD, elev’d WBC, elev’d ESR
ECTOPIC
Triad: abdominal pain, bleeding, + B-HCG
– may have shoulder tip pain, light vaginal bleeding, cervical motion tenderness, adnexal tenderness +/- mass, enlarged uterus
Risk factors: PID, tubal surgery, ectopic hx, abortions, endometriosis, IUD, Rx with infertility drugs
TORSION
- RARE
- sudden onset severe pelvic pain, N/V
- unilateral adnexal tenderness
- usually due to tumor (dermoid) or enlarged ovary