HISTORY:
RLQ pain for
Onset: , following
Radiation:
Severity: , / 10
Type:
Pattern:
Episode duration:
Worsening factors:
Alleviating factors: ,
, episodes ,
, episodes ,
, , , clots
, strong foul smell
, up to °, over
, ,
Last menstrual period: ago
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
CVA tenderness:
Pelvic: vulva , vagina , cervix , uterus , adnexa ,
Genital: , testicles , penis
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , , , ,
- Urinalysis, urine culture
- Abdominal X-ray
- Abdominal ultrasound
- CT scan of abdomen and pelvis
- Pelvic ultrasound
- STI screening for chlamydia and gonorrhea
- Colonoscopy
-
-
-
-
-
- Referral to gastroenterologist
- Referral to general surgeon
- Referral to gynecologist
- Follow-up in
- Return if pain worsens or if new symptoms develop such as fever, vomiting, or blood in stools