Patient Physical Examination

Vital Signs:

• Temperature

• Pulse

• Respirations

• Blood pressure

Temperature greater than 100.4 favors appendicitis, pyelonephritis, septic abortion, and moderate-severe PID. Temperature less than 99 is not often seen in these conditions.

Elevated pulse >100 is seen in hypovolemia (ruptured ectopic pregnancy), fever, and increased metabolic states (pyelonephritis, PID)

Respiratory rate increases some with fever, but increases quite a bit with hypovolemia.

Mood:

• Normal

• Anxious/worried

• Confused/inappropriate

• Lethargic

A normal mood is very uncharacteristic of patients with such serious medical problems as appendicitis, moderate-severe PID, pyelonephritis, renal colic, ruptured ectopic pregnancy, torsioned ovary, and bowel obstruction.

A confused, inappropriate or lethargic mood may be due to the hypovolemia of ruptured ectopic pregnancy, or the sepsis associated with pyelonephritis, moderate-severe PID, or septic abortion.

Patient's color is:

• Normal

• Pale

• Flushed

• Jaundiced

• Cyanotic

Any pain can cause a pale appearance to the skin,  but the peripheral vasoconstriction that accompanies hypovolemia from acute blood loss often creates a distinct pallor, or ashen-grey appearance.

Patients who have a fever are often flushed in appearance.

Neither jaundice nor cyanosis are associated with any of the common causes for pelvic or lower abdominal pain.

Greatest tenderness is:

• Entire abdomen

• Upper abdomen

• RLQ

• LLQ

• Suprapubic

• Lower abdomen

• No tenderness

Diffuse tenderness is associated with  ruptured ectopic pregnancy, gastroenteritis, functional bowel syndrome and bowel obstruction.

Upper abdominal tenderness is rarely associated with gynecologic illness.

Right lower quadrant tenderness increases the likelihood of appendicitis, ectopic pregnancy, ovarian cystovarian cyst, mittelschmerz and pyelonephritis, but diminishes the likelihood of diverticulitis.

Left lower quadrant pain favors an ovarian cyst, ectopic pregnancy, mittelschmerz, pyelonephritis, and diverticulitis, but makes appendicitis very unlikely.

Suprapubic pain favors cystitis, PID, abortion, endometriosis, dysmenorrhea, degenerating fibroid, gastroenteritis and functional bowel syndrome.

The abdomen is:

• Soft

• Voluntary guarding

• Involuntary guarding

• Mild rebound tenderness

• Moderate/marked rebound tenderness

The presence of voluntary guarding implies the patient is consciously protecting a sore area within the abomen, such as appendicitis, ovarian cyst, ectopic pregnancy, PID.

Involuntary guarding and moderate/marked rebound tenderness are characteristic of peritonitis, such as might be seen in appendicitis, moderate-severe PID, ruptured ectopic pregnancy, torsioned ovarian cyst, diverticulitis, or bowel obstruction.

On abdominal palpation:

• No masses

• Mass central lower abdomen

• Mass RLQ

• Mass LLQ

• Mass upper abdomen

A mass in the central lower abdomen is usually the uterus. It may be enlarged because of a pregnancy or fibroid tumors. A uterus that can be palpated on abdominal exam is at least 12-weeks size.

Bowel obstruction may lead to a mass, but is less common than uterine enlargement.

Diverticulitis can form a mass, but it is usually in the LLQ and usually not felt abdominally.

Appendicitis can form a mass, but it is usually in the RLQ and usually not felt abdominally.

Bowel sounds are:

• Normal

• Silent

• Hyperactive

• High-pitched, rushes

Diminished bowel sounds are non-diagnostic and common.

Absent bowel sounds are seen in appendicitis, diverticulitis, bowel obstruction and moderate-severe PID.

Bowel obstruction may also demonstrate high-pitched sounds, coming in rushes as bowel contents are squeezed through a constricted lumen.

CVA pain/tenderness is:

• Present

• Absent

Pain and tenderness in the area of the costovertebral angle is classically associated with pyelonephritis and sometimes renal colic. In these cases, the findings are usually one-sided.

Conversely, the absence of CVA pain/tenderness makes the diagnosis of pyelonephritis very unlikely.

The vagina contains:

• Nothing abnormal

• Small amounts of blood

• Large amounts of blood

• Clots

• Pregnancy tissue

• Other

Blood in the vagina at times other than the menstrual flow is usually associated (in the presence of abdominal and pelvic pain)
 

The hymen is:

• Intact

• Not intact

• Not visualized

An intact hymen speaks against pregnancy complications and PID.
 

The bladder is:

• Tender

• Non-tender

Bladders are normally non-tender. Cystitis or endometriosis can cause the bladder to become tender.

Conversely, a non-tender bladder makes cystitis very unlikely.

Cervix inspection:

• No abnormal findings

• Purple discoloration

• Purulent (muco) discharge

• Tissue protruding from the os

• Bleeding from the os

• Other

Purple discoloration of the cervix is associated with any of the pregnancy abnormalities.

Purulent discharge is found in PIDand septic abortion.

Tissue protruding from the os is usually pregnancy tissue in a patient with abdominal pain. Other causes include polyps and prolapsing uterine fibroids.

Bleeding is usually associated with pregnancy abnormalities or hormonal abnormalities.

Cervical Palpation:

• No abnormal findings

• Cervix is softer than expected

• Tender to touch

• Mild pain on movement

• Moderate/severe pain on movement

• Dilated at least 1 cm.

• Other

Cervical softness occurs during pregnancy.

Tenderness of the cervix to touch (without movement) is a symptom of cervicitis.

Mild cervical motion tenderness is a non-specific finding demonstrated in many patients with pelvic pain from a variety of sources.

Moderate to severe cervical motion tenderness is characteristic of PID, ectopic pregnancy, appendicitis, endometriosis, and a torsioned ovarian cyst.

The uterine size is:

• Normal

• Slightly enlarged

• Moderately enlarged

A normal-sized uterus does not give any insight into the source of the abdominal pain.

Uterine enlargement is seen with pregnancy, pregnancy complications (including ectopic pregnancy), and fibroid tumors.

Uterine palpation:

• No abnormal findings

• Soft

• Irregular contour

• Mildly tender

• Mod/severe tenderness

Unusual amounts of uterine softness correlates with pregnancy and pregnancy-related complications.

An irregular contour almost always indicates the presence of fibroid tumors.

The uterus is not normally tender. Uterine tenderness is seen in pregnancy complications, PID, and endometriosis.

Left adnexa:

• Normal

• Tender mass

• Non-tender mass

• Tenderness, no mass

Right adnexa:

• Normal

• Tender mass

• Non-tender mass

• Tenderness, no mass

Adnexal masses can be very difficult to palpate, particularly if the patient cannot fully cooperate or if she is large in body mass. That said, negative findings are still of value in ruling out PID. It would be nearly impossible for the patient to have PIDand not have significant adnexal tenderness.

A tender adnexal mass suggests an ovarian cyst, ectopic pregnancy, endometriosis, or tubo-ovarian abscess.

A non-tender mass usually indicates an un-ruptured ovarian cyst or endometrioma. In the presence of a positive pregnancy test, a non-tender mass in the adnexa is usually a corpus luteum cyst.

Tenderness without a mass is characteristic of PID.

Culdesac:

• Normal

• Tender mass

• Non-tender mass

• Tenderness, no mass

• Tender nodules on uterosacral ligaments

A tender mass in the culdesac suggests appendicitis, diverticulitis, moderate/severe PIDwith tubo-ovarian abscess, ovarian cyst or ectopic pregnancy.

Non-tender masses are usually ovarian cysts or stool in the colon.

Generalized tenderness in the culdesac without a mass is usually related to peritoneal irritation from endometriosis, ruptured ectopic pregnancy, appendicitis, PIDor diverticulitis.

Tender nodules on the uterosacral ligaments (often best felt through combined vaginal-rectal exam) are characteristic of endometriosis.