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