Muhamad Na'im B Ab Razak (jacknaim) is a fresh graduate Muslim Doctor from Universiti Sains Malaysia and waiting for the enrollment into the housemanship program. Ambitious in pursuing master program in emergency and traumatology medicine and loves to spent his free time joining humanitarian missions, writing and speaks as an amateur public speaker in motivation and comparative religion. [HOME]

Right Iliac Fossa Pain for Woman In Reproductive Age Group


Answer

1) Five most likely diagnosis

a) Right ovarian torsion
b) Ruptured ectopic pregnancy
c) Acute appendicitis
d) Severe urinary tract infection
e) Ruptured diverticulitis.
f) Gastroenteritis
g) Endometriosis


2) History to be obtained

a) Ectopic pregnancy
- Last normal menstrual period
- history of sexual intercourse
- Per vaginal bleed
- Any history of ectopic pregnancy, assisted reproduction technique, pelvic inflammatory disease.
- Pain in the shoulder tips


b) PID
-History of PID
- Vaginal discharge
- multiple sexual partner or high risk behavior


c) Urinary tract infection
Dysuria, increase in frequency, urgency, fever

d) Diverticulitis
Crampy pain associated with change in bowel habit
Systemic sign of infection


e) Appendicitis
often difficult to differentiate from others. ALVARADO score could be used but not sensitive. Need to exclude other causes of gynaecology related problem before making a diagnosis of appendicitis.


f) Endometriosis
pain related to menses

g) Ovarian torsion
Any history of diagnosis of ovarian mass
Any palpable mass/ abdominal discomfort in lower abdomen


3) Physical examination to elicit

- Patient vital sign to triage the patient. Patient with ectopic pregnancy or perforated viscus usually look more ill and abnormal vital sign.
- pallor as patient can have intra abdominal accumulation of blood from ruptured ectopic pregnancy
- Abdominal distension (due to blood or gass)
- look for any generalized guarding, localized guarding or voluntary guarding
- Psoas signs, Rovsing sign and Obturator sign
- Any palpable mass in the right iliac fossa
- Vaginal examination to elicit adnexa tenderness or cervical excitation
- Per speculum examination to look for any bleeding/ blood clot.
-Per rectal examination if necessary to elicit any per rectal bleeding, impacted stool.


4) Investigation

- Full blood count to look for hemoglobin level and total white blood count
- Urinary pregnancy test
- Bedside ultrasound
- Erect CXR to look for any gas under diaphragm
- Urine FEME and C&S