Pelvic Pain

HISTORY:

Pelvic pain for ‍ ‍hoursdays

Onset: ‍gradualsudden, following ‍

Location: ‍diffuse

Radiation: ‍none

Severity: ‍mildmoderatesevere, ‍012345678910 / 10

Type: ‍crampingburning

Pattern: ‍constantintermittent

Episode duration: ‍ ‍secminhoursdaysweeksmonths

Worsening factors: ‍none

Alleviating factors: ‍none, ‍effectiveineffective

‍missed period, ‍one cycles missed, ‍possibility of pregnancynot sexually active

‍vaginal bleeding

‍vaginal discharge, ‍clear, ‍thin

‍fishy smell

‍constipation

‍diarrhea

‍nausea

‍vomiting

‍bloating

‍dysuria

‍frequency

‍hematuria

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍weight loss, ‍ ‍lbskg over ‍ ‍weeksmonths, ‍unintentionalintentional



Gynecological history:

Last menstrual period: ‍ ‍daysweeksmonths ago

Menstrual cycles: ‍ days, ‍regularirregular

Menarche: ‍ years old

G‍01234 P‍01234 A‍01234

Last Pap smear: ‍ ‍monthsyears ago ‍never

Coitarche: ‍ years old ‍never

Contraception: ‍yesno ‍oral contraceptives

Condom use: ‍alwayssometimesnever





EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Anorectal: DRE ‍normal, anus ‍normal

Pelvic:

- External genitalia: ‍normal, ‍inguinal lymphadenopathy

- Vagina: ‍normal, discharge ‍normal, ‍malodorous

- Cervix: ‍normal

- Uterus: ‍normal, ‍no cervical motion tenderness

- Adnexa: -R ‍normal, -L ‍normal

- Tests performed: ‍Pap test, ‍HPV DNA, ‍vaginal culture, ‍chlamydia/gonorrhea, vaginal pH ‍< 4.5> 4.5, whiff test with KOH ‍negative

- Performed with chaperone



ASSESSMENT:

‍Pelvic inflammatory disease ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍CBC, ‍CRP, ‍TSH, ‍prolactin, ‍FSH, ‍LH, ‍estradiol, ‍ß-hCG

- Urine: ‍urinalysis, ‍urine culture, ‍pregnancy test

- STI screening for chlamydia and gonorrhea

- Pelvic ultrasound

- CT scan of abdomen and pelvis

- Colonoscopy

- ‍Analgesics

- ‍Antibiotics

- ‍Oral contraceptives

- Referral to gynecologist

- Referral to gastroenterologist

- Follow-up in ‍ ‍weeksmonths

- Return if pain worsens, if new symptoms develop such as heavy bleeding or irregular periods, or if symptoms do not improve with treatment

- Go to ER if severe abdominal pain, fever, or heavy bleeding occurs