PELVIC PAIN

History:
1. Pain
• Characteristics of the pain site, time and nature
• Relationship of pain to various body functions eg. Veinal bleeding or
icrturition
• Past gynecological or obstetrical events
• Menstrual Hx (eg.LMP)
• Symptoms of possible pregnancy (eg.breast changes and woman’s own
impression)
2. Shock
3. N/V

(NB: Distension: This is common in GIT problems but not gynaecological problems)

Examination:
1. Paleness (conjunctiva)
2. Pulse rate
3. Arterial BP
Temperature
4. Abdominal examination (helps localize pelvic causes)
5. Observation: Show old scars and degree of distension (site of pain can be elicited
from woman at this point)
6. Gentle palpation of abdomen leading to lower pelvic zones may help localize it
further
7. Firmer examination: Reveals guarding or rebound tenderness
8. Bimanual vaginal exam: Tenderness in pelvic organ will limit thoroughness of
exam as woman will guard ig pain on moving the cervix (called cervical
excitation). Moving cervix to side of ovarian or tubal mass will cause intense
paoin by a furthr stretch of the overlying peritoneum. Moving the cervix towards
the opposite side will decrease pain by releasing tension of peritoneum
9. Rectal exam: May be needed but usually one can assess acute pouch of Douglass
problems at vaginal assessment. If structural changes are sought at the back fo the
pelvic cavity then rectal examis useful (Eg.endometriotic lesions on the
uterosacral ligaments or to differentiate from appendicitis)

Investigations:
• Hb (chronic bleeding)
• Differential WCC
• Urine cells and organisms to diagnose urinary infection
• hcG levels to check for pregnancy
• High vaginal swab and cervical swab to test for genital tract infection
• X-rays may be used to check for bowel obstruction
•
 • Ultrasound is useful to check for pevlci organs (especially using a vaginal
probe). It is used to look at:
(1) Changes in ovarian morphology and size: Cysts, PCOS, irregular
masses
(2) Fallopian tube: Swollen tube from pyo or hydrosalpinx and
ectopic pregnancy
(3) Uterine size detected: thickness of endometrium is shown,
presence of pregnancy sac detected as early as 5 weeks,
embryonic parts and hetal heart beats by 6 weeks form LMP
(4) Fibroids of uterus
(5) Pouch of Douglass fluid detected in low as volume 7ml. This can
indicate blood loss form ectopic pregnancy

CONDITIONS
1. Vaginal trauma: Intercourse can damage it (after long period of abstinence).
Lower end (usually obvious but can be labial or fourchette), upper end (vaginal
guarding to prevent easy passage of speculum. So hard ot see), haematoma
(paravaginal or paracervical haematoma) Treat: Vaginal repair under anaesthesia
2. Uterine fibroids (leiomyomata): Bengin fibromuscular swellings aririsng in the
muscular wall of the uterus. These are oestrogen sensitive. Include submucous
(lying immediately below endometrium and enlarging the surface if the uterine
cavity leading to menorrhagia. Fibroids can form polypi which extrude though
cervix),intramural (commonest fibroid, surrounded by smooth muscle, enlarges
uterine wall and distorts venous drainage), subseorus (beneath peritoneum on
outer uterine surface-can become pedunculated with risk of torsion or grow into
broad ligament).. The fibroids may degenerate and outgrow their blood supply
forming : hyaline (aseptic necrosis with loss of muscle cel structure and
calcification), cystic (sequel to hyaline change with subsequent breakdown and
cyst formation giving honeycomb appearance), fatty (partial necorsis results in
development of fatty substances which can undergo calcification that is visible on
X ray and ultrasound), red (necrobiasis-particularly encountered in mid-trimester
of pregnancy of early puerperium,. Breakdown of blood supply by thrombosis
leads to necrosis and suffusion with RBCs), sarcomatous (malignant change
reported in small percentage of fibroids).

(Submoucosal fibroid: protrude into uterine cavity lined by enodmetrium and increased
SA and vascularity cause menorrhagia. Uterus recognized fibroid as abnormal and tires to
extrude it though cervix so get secondary dysmenorrheoa. Constant low abdo pain with
fiboird degeneration.

Symptoms: Asymptomatic (found incidentally on exam), tightness of waisbadn fo

clothes, pressure (bladder compression cause frequency, impaired urinary stream. In
supporting ligamenets it causes back ache and pelvic heaviness), pain (associated with
red degeneration or torsion of sebserous pedicles. Dysmenorrhoea may indicate presence
of submucous fibroid), menstrual disturbances (menorrhagia, metrorrhagia-prolonged
menstruation, irregular and intermittent bleeding associate d with polyps and other
surface lesions often)

Investigations: Ultrasound (define the location, dimension and consistency)

Diagnosis: Bimanual palpation reveals hard, rounded, nontedner, bosselted mass moving
when cervix displaced. It grows fast in pregnancy and shrinks at menopause or with
antigonadotrophic hormone therapy (NB: Fibroids form a pseudocapsule by compressing
surrounding uterine muscle)

Aetiology: >30yo, common in Afro-Carribean, nulliparous and women with low fertility
and often family Hx

DDx: Pregnancy, ovarian tumour (unilateral does not move with cervical displacement),
adenomyosis (diffuse and tender uteirn enlargement)

Treatment:
(a) If small and asymptomatic then annual exam and U/S
(b) Menstrual or pressure symptoms may dictate surgery
(c) Pain-requires analgesia
(d) Heavir and longer periods perform surgery
(e) Embolization under radiological control (cannula passed from femoral artery to
uterine arteries and inject tiny silicon particles causing fibroids to degenerate.Pain
relief essential for 48hrs. Larhe and multiple fibroids increased risk of hyserecotmy
(means can’t have more children)
(f) SurgeryL Abdominal hysterectomy (if family complete and woman>40yo, or uterus is
large and distorted by fibroids), Vaginal hysterectomy (when fibroids small and few
and associated prolapse of uterus),. Myomectomy(I want more children or if desire to
retain uterus), submucous fibroids (need to be resected with laser or diathermy via a
hysteroscope)
(g) Effects on childbearing: Miscarriagem pain from red degeneration, premature labour,
dysfunctional uterine contractions, malpresentation or obstructed labour (as pelvis is
obstructed), postpartum haemorrhage and retained placenta, conservative
management in pregnancy
(Aim is for a vaginal delivery but if caesarean seciot is necessary then incise around the
fibroids and remove or incise as severe haemorrhage develops so need for hysterectomy)

3. Uterine adenomyosis
This is wehre endometrial glands of stroma found in uterine musculature. If localized to
one site called an adenomyoma. (Uterus is enlarged and thick-walled with no
pseudocapsule formation, as in fibroids. The endometrial glands sometimes do not all
menstruate, as they derive from the basal layer of the endometrium)
Found in women 35-40yo with reduced fertility. Symptoms are dysmenorrhoea,
menorrhagia, and dysparenunia. Signs: Uniformly enlarged uterus and tender on
palpation (particularly premenstrually)
DDX: Uterine fibroids, early pregnancy, uterine infection
Treatment: Norethisterone, danazol, gonadotrophin analogues (buserelin or goserelin).
Abdominal hysterecotm is the treatment of choce but occasionally can resect affected
area.

4. Endometritis
Acute condition associated with ascending infection. Disease can result form post-
abortional infection, criminal abortion, excessive curettage, intrauterine device
infection or postpartum (after C-section or rarely from blood-borne TB)
Findings: Acute infection: Irregular bleeding, uterine tenderness. Chronic infection
(secondary amenorrhoea, infertility due to adhesions developing leadind to
partial/complete occlusion of uterine cavity-Asherman’s syndrome)

5. Pyometra
Infeciton lead to pus which blocks the Fallopian tubes and cervix. Commoner in older
women. It causes pain (Stretch uterus muscle), occasional acute bursts of
toxamiea(blous of pus forced into vein), chronic ifnetion (low grade temp and
malaise), occasionally pus forced through cerix to produce purulent or bloodstained
discharge. Pyometra oten associated with cancer of cervix so of have pyometra have
hysteroscopy and D&C under antibitoitc toexlcude malignancy

6. Fallopian tube torsion-assoicated with torsion of ovaries and treat by laparotomy

/laparoscopy (if tissues healthy then conserved and secured via suture to side wall
of pelvis to prevent retorsion), if tissues devitalized the ovary and tube removed

7. Salpingitis: Asceding infection from vagina through cerix. Associated with

intercourse, transcervical surgery (D and C or evacuation), intrauterine foreign
body (eg.IUD), retained products of concetion, (Blood-borne infection rare)

8. Acute salpingitis: Fallopian tube gets red, swollen and distorted with obstruction
at abdominal end so pyosalpinx forms which becomes a hydrosalpinx. Peritoneal
inflammation with adhesions to serosal surface occurs leading to a pelvic abscess
and septicaemia. . It is usually bilateral and can cause infertility (destruction of
cilia).Chronic hydrosalpinx can become reinfected. Get pyrexia, tachycardia,
dehydration. Lower abdo pain with guarding, if parietal peritoneum involved then
rebound tenderness and distension. Vaginal exam: Cervical excitation ain
(bilateral), tender and normal sized uterus, fullness in fornices and tenderness
over tubes, vaignal discharge. Invesitgations: Organsism (form cervical
discharge), gonorrhoea, E.coli/haemolytic strep/staph found in puerperium and
postaboriton, Clostridium welchii thive on placental products (dead tissue),
Chlamydia, leucocytosis, laprasopcy only way of making tru Dx (remember to
take serosal swabs). DDXL Appendicitis,ruptured ecotpic pregnancy (faint,
shoulder tip pain if intraperitoneal bleeding, unilateral tenderness and pregnancy
+ve, no pyrexia), ovarian tumour torsion (localilzed pain, unilateral, pregnancy
negative, unltraousnd confirms), pyelonephritis (loin tenderness and pus in urine),
intestinal obstruction (colicky pain and abdo distension). X rays show fluid
levels). Treatment: Sit paitnet upright, IV infusion, broad spectrum antibiotic
 (until high vaginal swab reveals reports) (Clindamycin, augmentin, cephradoxyl
or Flagyl suitable-continue antibiotics until after acute phase fo 2-3 weeks on
doxycycline), analgesia and gluids, refer to GU clinic for treatment o partner and
contact traciting (for radical treatment if Dx is in doubt then exploratory surgery
and minimal interference eg.drainage and antibiotic cover)
9. Chronic salpingiits Sequel to acute slapingitis but lower grader purulent organism
(eg.chlamydia) Get persistent recurrent episodes of lower abdo pain, dysparenunia
(deep), congestive dysmenorrhoea, heavy periods, subfertility. Invesitgaitons: U/S
scan of pelvis and laparoscopy if no recent acute episode dye installation with
antibiotic cover. Long term dequelae: Subfertility and ectopic pregnancy
10. Ovarian infection: Ovary not inflamed on tis own but infalmmaed in general
pelvic infection (salpingo-parametro-oophoritis better description of pelvic
abscess). Mumps can affect the ovary and casue ovarian swelling and upset
ovulation (rare but if it occurds is temporary unlike the male)
11. Ovarian tumours: Usually asymptomatic but can cause abdominal distension
(increased waist size together with shiny skin due to stretch and peau de orange
due to oedema), pressure on rectum/bladder/lymphatic systm (pressure or back
symptoms), pain (due to complications suchas torsion, rupture, haemorrhage) (can
be peritoneal irritation leading to symptoms of shock and abdominal muscle
guarding. Torsion accompanied byvomiting). After resuscitation do a
laparscopy(can deal with ovarian cyst) but if doubt on whether tmour is malignant
then open the abdomen at laparotomy and perform formal removal. Can also be
hormonal secretion (oestrogens secreted by granulosa cell tumours leading to
menstrual upset or androgens secreted by arrhenoblastomacausing
masculinization). (NB: Palpation ca feel firm ovarian cyst, percussion may show
central dullness with resonance at flanks, but if ascites is present then sign is lost
and shifting dullness replaces it. Pelvic exam-if benign mass separate from uterine
body and mobile and if feixed the infection/endometriosiss/malignancy should be
suspected). INvestigatiosn: U/S of abdomen-detect mass and ascites. Tumour
markers can be raised (eg.CA125)
12. Ovarian cysts:
(a) Follicular cysts: These are normal Graafian follicles that are enlarged and
unruptured (normal ovary contains one or more small cysts). They are not
neoplastic and disappear by resorption of fluid (difficulty in distinguishing
follicular cyst from serous cystadenoma)
(b) Corpus luteum cyst:Lined with luteal cells (derived from granulosa layer). This is
where the corpus luteu reaches 3cm or more and can appear cystic. Sometimes
apart from pregnancy corpus luteum persists becoming cystic and causing
amenorrhoea folowe dby bleeding. Haemorrhage into corpus luteum cause pain
(can resemble symptomsof ecotpic pregnancy)
(c) Haemorrhagic cysts: Bleeding into Graafian follicle or corpus luteumNEed
haemostasis of affected area and shell out haematoma
(d) Theca luteal cyst: Found in association with reiased hCG levels (hydatidiform
mole, choriocacinoma, gonadotrophin therapy). Both ovaries enlarged with
multiple cysts lined by luteal cels. Ovaries return to normal when hCG levels
reduce
13. New growths
(a) Serous cystadenoma: Benign tumour contains protein rich fluid resemble serum)
and contains papillary growths. Bilateral tumours seen and can change to
malignant growth.
(b) Mucinous cystadenoma (commonest): Benign growths that contains viscus mucin
and cyst grows slowly and reaches large size. IT is mutlilocular (each loculus
lined by columnar epithelium ciliated and proliferate for form papillary folds.)
Can change to malignant form
(c) Pseudomyoxoma peritonei: Occurs if contents of cyst leak (spilled into peritoneal
cavity) (epithelial cells lining cyst proliferate eand produce mucinous scites which
fulls whole peritoneal cavity filled with mucoinous material) (can alo arise form
mucocele of appendic and found n males/females)
(d) Fibroadenoma: Benign tumour (arise form CT as a solid non-encapsulated tumour
which can be bilateral and grow to 20cm. Normal ovary compressed but not
invaded. Benign tumour composed of whorls of fibrous CT resembling ovarian
stroma. Assoicated with ascites, hydrothorax, hydropericardium. This association
is known as Meig’s syndrome (found in Brenner tumour, granulosa cell ro theca
cell tumour).
(e) Brenner tumour: Found in postmeopusal women (small and symptomsless
tumour). Solid tumour with nests of epithelial cells enclosed in fibroud issue
(cavities arise in epithelial nests contain mucin like mucinous cystadenoma).
Meig’s syndrome.
(f) Germ cell tumours: Arise form undifferentiated sex cells. Seen in ovary
(dysgerminoma-seen in infantile genitlaia, undescended testes,normal people-
secretes gonadotrophins os positive pregnancy test obtianed) and testes
(seminoma). Consists of epithelieal cells (round cells like
spermatocytes)arranged in alveoli separaed by septa of fibroud tissue infiltrated
with round cells, (resemblelymphocytes). Occurs in young patientsand can
become malignnt.
(Note: Endodermal sinus tumour or embryonal carcinoma can occur with
dysgerminoma)
(g) Dermoid or benign teratoma. Occurs in 15-30yo, arises from unfertilized ovum
and occurs in reproductive period, multiple and bilateral. A dermoid is a thick-
walled cyst with solid parts. Torsion is common. The cysts if lined by squamous
epithelium and contains teeth, cartilage, GIT epitheliu, nervous tissue, thyroid
tissue, sebaceous glands, hairs, fatty sebaceous secretion resembling sebum.
Malignant change can follow(to sqaumous epithelioma or embryonal carcinoma
and hyperthyroidism can follow a being teratoma)
(h) Solid teraotma: (cotnians primitive tissues of ectoderm, kesoderm, and endoderm
so tumour contains all variety of bizarre hsiotlogical pattern. Very malignant)
(i) Gonadoblatoma: Occurs in abnormal gonads and in individuals with sex
chromatin negtative. Consists of large germ cells like those of a dysgerminoma
and small cells like a granulosa cells. Can show hormonal activiy and become
malignant
(j) Grandulosa cell tumourL Resemble granulosa cells (polygonal with deeply
staining nuclei). Arranged in rosettes (clear space between them and strands of CT
 run between granulosa cells). Malignant change can occur and they secrete
oestrogens.Occur at any age and in infants cause precocious puberty with uterine
bleeding. In adult woman can cause profuse irregular uterine bleeding
(hyperopestroenized endometrium). In postmenopausal women irregular utrine
bleeding is caused, with oestrogenizaion of uterus, vulva and vaigna.Therre can
be carcinoma o uterus with hyperoestrogenized endometrium.
(k) Thecoma: Solid tumour and Meig’s syndrome can occur. Yellow fatty areas show
up sections stained for fat are scattered among the fibrous tissue cells. These are
theca lutein cells. A mixed granulosa cell tumour and theocma also occurs. It
occurs in women>30yo.Can present with a pelvic mass or with uterine
harmorrhage or both (ascites and pleural effusions can be seen). High incidence of
endometrial carincoma associated with thecoma
(l) Sertoli-Leydig cell tumour: Called androbalsotma or arrhenoblastoa this tumour
causes virilism from its testosterone metabolism, but is rare. Tumour can be
cystic/solid and potentially can be malignant. Cells consist of undifferentiated
mesenchyme and can be arranged in tubules as in the testicle

(Exmaple: 2yo F presents with unlilateral abdo pain, cvomiting, abdo rebound and
guading. She is apyrexial and her LMP was one week ago. Likely to be a torted/twisted
demroid cyst(not PID as PID is bilateral, not bleeding into rupture of a cyst which causes
peritonism but not vomiting, and torted ovarian cyst commonly associated with vomiting)

Dysmenorrhoea
This is pain associated with menstruation occurs in two main forms:
• Primary, spasmodic
• Secondary, congestive or acquired

(1) Spasmodic dysmenorrhoea: Very common and most normal women have some
discomfort with onset of menstruation. Pain is severe during first hours-days of
period. It can be continuous or spasmodic like colic, accompanied by vomiting or
faintig, felt in pelvis and lower back, radiating into legs, diarrhea. (Pain is caused
by excessive PG producing contractions of uterine muscles in first days of
menstruation. Associated with adenomyosis). Management: Simmple analgesics
(aspirin, paracetamol, codeine. Mefenamic acid gives good relief of pain),
hormone therapy (OCP-inhibit ovulation and causes painless bleeding)
(2) Secondary, congestive or acquired dysmenorrhoea: Occurs>30yo. Pain beigns
before menstruation and relieved when bleeding starts. Felt in pelvis and back and
made worse with exertion.Other symptoms such as menorrhagia and
dysparenunia. This type of dysmenorrhoea occurs with a physical cause (chronic
pelvic sepsis, endometriosis, acquired fixed retroversion of uterus, fibroids)

Endometriosis
Presence of endometrium outside of uterusThe tissue responds to hormones like normal
endometrium, and occurs in second half of a woman’s reproductive life between the ages
fo 30-45yo and regresses at menopausse. Occurs in women who are childless or have few
children, and full-term preganancy leads to regression. Common in Europeans.
.Endometriosis consist of endometrial glands and stroma and tissue bleeds in reposnse to
hormone cyclical changes but no escape of blood which gets encysted. Infiltration of
surrounding structures like bowel occurs with fibrosis. These enometriotic areas vary
from pinhead size to large cyst with tarry material (chocolate cyst).

Endometriosis commonest in pelvis and occasionally found in sites like pleura and
umbilicus. It can affect the:
• ovaries which take the form of endometrial cysts continaing blood or chocolate
cysts adherent to surrounding tissues(typical endometrial glands not always seen
as destroyed by large cysts).
• Pelvic peritoneum is often affected(eg.over back of utrus, gfallopian tubes, pouch
of Douglass-present as black odules with scarrign and puckering of peritoneal
surface and adhesions can form between these and back of uterus casing fixed
retroversion).
• Uterine ligaments(uterosacral and rectovaginal ligaments, roud ligament, inguinal
ligaement involved-can present as tumour in groin)
• Bowel: Intestines and rectum infiltrated and causes bowel obstruction
• Urinary tract: Haematuria and painful micturition
• Abdominal wall: If isolated lesion in umbilicus (cyclincial bleeding) and occurs
in scar sfollowing operation (eg.Caesarean )
• Perineum and vaigna: Seen in perineal scars and vaginal wall

Clinical features:
• Pain-three types: congestive dysmenorrheoa (begins with mensturaiton), ovulation
pain (midcycle), dyspareunia (felt in deep pelvis due to pressing on uterosacral
ligaments and rectovaignal septum in coitus)
• Infertility (damage to tubes)
• Disturbance of menstruation: Menorrhagia (if deposits in mometrium) and shorter
cycles and prolonged bleeding can occur (adenomyosis)
• Other symptoms: haematuria, dysuria, intestinal obstruction, pain on defaecation,
occasionally chocolate cyst can rupture

Physical signs:Msot common present with fixed retroversion of uterus with enlarged,
tender ovaries adherent behind it. Deposits in uterosacal ligaments palpable as tender
nodules. La[aroscopy needed to establish diagnosis.
Treatment (Cnservative-as occurs in reproductive period, doesn’t become malignant and
regresses at menopause)
• Hormone therapy: Should occur after making diagnosis via laparoscope and if
chocolate cysts they are drained and if local areas of endometriosis can be
coagulated with laser/diathermy through laparoscope.Danazol inhibits
megonadotrophin secretion and sppresses menstruation (ensure women is not
pregnant and danazol is not a contraceptive), progesterone (norethisterone or
medroxyprogesterone suppresses menstruation), GnRH agonists (inhibit ovarian
function)
 • Surgery: Laparoscopy: Diathrmy or laser (if pelvic mass >5cm, acute rupture of
cyst or intestinal obstruction then surgey needed-usually try conservative
approach aiming to leave uterus and ovaries, t if woman doesn’t want children
and intractable then hysterctom with bilateral salpingo-oophorecotm)

Premenstrual tension
BEhaviorual symptoms and physical signs in second half of menstrual cycle and
abolishes after menstruation. Symptoms include: Irritability, depression, lassitude,
insomnia, lack opf concentration, oedema due to fluid retention, abdo swelling, swollen
fingers/ankles, weight gain and migraine. Occurs in luteal phase and can have
endogenous depression and suicide during this time. Thought caused by rennin-
angiotensiin, changes in monoamine HT, reduction in endogeous opioids)
Treatment: Replace progestogens (if deficient in second half), oestroge to suppress
ovulation, oral contraceptive, danazol (stops ovulation), primrose oil, pyridoxine VitB6)
(can affect dopamine and serotonin metabolism), antidepressant during premenstrual
phae can help)(eg.fluoxetine)

Abdominal organs
1. Pyelonephritis:Abdo pain (loin apin and costovertebral angle tenderness), pyrexia,
shivering. Examine urine for pus cells and organism. Treatment: Bedrest, fluids,
antibiotics(for ureteric stone pehtidine as analgesic and antispasmodic)
2. Appendicitis: Due o enlarging uterus appendix pushed up from RIF to right
paracolic gutter. Surgery. (higher mortalityof appendicits in pregnancy as
mother’s scaredof operating so leave it off, so must emember appendicits cause
higher mortality formother and fetus for not operating than operitn on it which
cures it)
3. Rectus haematoma:Deep epigastric arteries and veins stretched by growing uterus
and after severe attack fo coughing one fo these veins ruptures (haematoma). Pain
localized under one segment of rectus muscle but after a few hours this sign
spreads. If late can be anaemia due to loss of blood into haematoma. Laparotomy
diagnoses it and as it’s usually too late to ligate veins surgery not needed
4. Bowel problems: Refer to surgical colleague
Condition History Examination Investigation Ultrasound
scan
Ectopic -Pain-sudden Rebound Hb Empty uterys.
pregnancy onset, guarding, normal/decreased Free fluid in
constant, decreased BP, WBC normal pouch of
shoulder tip increased pulse, hcG+ Douglass
-Other: temp<37, vaginal ?Adenexal
Sudden exam-unilateral mass
collapse, cervical
period of excitation, uterus
amenorrhoea, small for dates, so
minivaginal closed
bleeding
Acute Pain-gradual Guarding?rebound Hb normal, No abnormlity
salpingitis onset, T>37.5, increased WCC, detected
constant, BPnormal, pulse hc-ve, +ve high
generalized, , raised. Vaginal vaginal swab
bilateral exam –bilateral
-Other-vaignal cervvcal
dischargem excitation
irregular
menses
Fibroid Pain-gradual Tender over Hb equal, WBC Fibroid seenin
degeneration onset, fibroids qual or uterine wall
constant, T 37-37.5 increased, hcG with cystic
generalized Vaginal exam-no negatuve areas
Other- cervical
emnorrhagia excitation,
enlarged uterus
Ovarian cyst
accident:
Torsion Pain-sudden Rebound Hb normal, Echogenic
onset, tenderness WBC normal or mass seen
constant, T 37-37.5 increased, hCG separate from
maybe getting BP equal, pulse negatuve uterus? Free
 less raised fluid
Other- Vaginal exam-
vomiting unilateral cervical
excitation,
adnexal mass
Rupture Pain –sudden Rebound, Hb normal, Free fluid in
onset, guarding, T 37, WBC normal, pouch of
constant , pulse, B normal hCG negatuve Douglass. No
getting less Vaginal exam- cyst seen
Other- generlized
irregular tenderness only
menses
Haemorrhage Pain-sudden Renound, Hb normal or Echogenic
onset, guarding T37, BP increased, WBC cyst, free fluid
constant, normal, pulse normal, hCG-ve if ruptured
becoming less raised, vaignal
exam-unilateral
cervical
excitation,
adenxal mass
Appendicitis Pain-gradual Rebound Hb normal, No
osnet, right guarding, right increased WBC, abnormality
sided sided tenderness, hCG negative detected
Other- T=37-37.5, BP
anorecia, no normal, raised
bowel sounds, pule, vaignal
N/V exam-no
abnormality
detected, PR-
empty rectum,
right sided
tnderness
Pyelonephritis Pain-in loin, Loin tenderness, Hb normal, Renal
colicky T>37.5, vaginal raised WBC, pelvicalyceal
Other-N/V, exam-no hcG-ve, dilatation
rigors, dysuria abnormality MSU+ve Palvis-no
detected abnormality
detected
Obstruction Pain- Reound, guarding, Hb normal Pelvis-no
intermittent, distension WBC normal or abnormality
generalized No bowel sounds. raised detected,
colicky Temperature 37 hcG-ve AXR-dilated
Other-N/V, Vaignal exam-no loops with
anorexia, abnormality fluid levels
bowels not detected
open PR-empty rectum