Pelvic Pain
Age: years old
Gender: female
HISTORY:
Presents with a - history of pelvic pain
Onset was , started
Location is
Radiation to
Rated at / 10
Described as
Pattern , worse during the
Episodes last for , recur times per
Worsening factors:
Alleviating factors: ,
Associated symptoms: *Try using right-click for negatives*
, cycles missed,
, , , fishy odor
, episodes ,
, episodes , ,
, up to °, over
, over ,
Gynecological history:
Last menstrual period: ago
Menstrual cycles: days,
Menarche: years old
G P A
Last Pap smear: ago
Coitarche: years old
Contraception:
Condom use:
STI risk factors:
Contributing factors:
no history of: , , , , , ,
no use of: ,
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Abdomen: , , , , bowel sounds , ,
Anorectal: DRE , , , anus
Pelvic:
- External genitalia: , ,
- Vagina: , , discharge ,
- Cervix: , ,
- Bimanual exam: , uterus , adnexa ,
- Tests performed: , , pH , KOH sniff test
-
ASSESSMENT:
DDx: pelvic inflammatory disease, ectopic pregnancy, ovarian cyst rupture, ovarian torsion, endometriosis, uterine fibroids, urinary tract infection, functional pelvic pain, miscarriage, irritable bowel syndrome, inflammatory bowel disease, diverticulitis, constipation, appendicitis, interstitial cystitis, kidney stones, prostatitis, testicular torsion, inguinal hernia, colorectal cancer, rectal prolapse, sexually transmitted infections, chronic pelvic pain syndrome
PLAN:
Investigations:
- Blood work: , , , , , , ,
- Urine: , ,
- STI screening for chlamydia and gonorrhea
- Pelvic ultrasound
- CT scan of abdomen and pelvis
- Colonoscopy
Treatments:
-
-
-
Further care:
- Referral to gynecologist
- Referral to gastroenterologist
- Follow-up in
- Return if pain worsens, if new symptoms develop such as heavy bleeding or irregular periods, or if symptoms do not improve with treatment
- Referral to ER if severe abdominal pain, fever, or heavy bleeding occurs
HISTORY: Associated symptoms: EXAM: Pelvic: ASSESSMENT: PLAN: