HISTORY:
Pelvic pain for
Onset: , following
Location:
Radiation:
Severity: , / 10
Type:
Pattern:
Episode duration:
Worsening factors:
Alleviating factors: ,
, cycles missed,
, ,
, 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:
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Abdomen: , , ,
Anorectal: DRE , anus
Pelvic:
- External genitalia: ,
- Vagina: , discharge ,
- Cervix:
- Uterus: ,
- Adnexa: -R , -L
- Tests performed: , , , , vaginal pH , whiff test with KOH
- Performed with chaperone
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , , , ,
- Urine: , ,
- STI screening for chlamydia and gonorrhea
- Pelvic ultrasound
- CT scan of abdomen and pelvis
- Colonoscopy
-
-
-
- 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
- Go to ER if severe abdominal pain, fever, or heavy bleeding occurs