What is the appropriate documentation for a female patient of reproductive age presenting with lower abdominal pain, including history, physical examination, laboratory tests, and imaging studies?

Documentation Template for Female Patient of Reproductive Age with Lower Abdominal Pain

Chief Complaint

Document the specific characteristics of the abdominal pain, including:

• Onset and duration: Abrupt onset suggests vascular catastrophe or perforation; gradual onset suggests inflammatory process 1, 2
• Location: Right lower quadrant (appendicitis), left lower quadrant (diverticulitis, gynecologic), diffuse (requires broader evaluation) 1, 2, 3
• Quality: Colicky pain indicates bowel obstruction; constant pain suggests inflammation or ischemia 2
• Severity: Pain out of proportion to examination findings should raise immediate suspicion for acute mesenteric ischemia 1, 2
• Associated symptoms: Fever, nausea, vomiting, diarrhea, vaginal bleeding, vaginal discharge, last menstrual period 1, 2, 4

Past Medical and Surgical History

Critical elements to document:

• Prior abdominal surgeries: Any prior laparotomy makes adhesive obstruction the leading diagnosis (55-75% of small bowel obstructions) 2
• Previous episodes: History of diverticulitis, appendicitis, ovarian cysts, ectopic pregnancy 5, 2
• Gynecologic history: Last menstrual period, possibility of pregnancy, history of pelvic inflammatory disease, sexually transmitted infections 4, 3
• Cardiovascular disease: Atrial fibrillation present in nearly 50% of embolic acute mesenteric ischemia patients 2
• Medications: Oral contraceptives (predispose to mesenteric venous thrombosis), psychotropic medications (cause constipation predisposing to volvulus) 2

Physical Examination

Vital Signs

Document and interpret abnormalities:

• Tachycardia: Most sensitive early warning sign of surgical complications; triggers urgent investigation even before other symptoms develop 1, 2
• Fever, tachycardia, and tachypnea together: Predict serious complications including anastomotic leak, perforation, or sepsis 1, 2
• Hypotension: Suggests bleeding or sepsis 2

Abdominal Examination

Specific findings to document:

• Inspection: Distension, asymmetry, surgical scars 2
• Palpation: Location of maximal tenderness, presence of mass or resistance (more often leads to hospital admission), rebound tenderness, guarding, rigidity 5, 6
• Percussion: Tympany suggests bowel obstruction 2
• Auscultation: Absent bowel sounds suggest ileus or late obstruction; high-pitched sounds suggest early obstruction 2
• Special signs: Murphy's sign (right upper quadrant pain with palpation during inspiration suggests cholecystitis) 2

Pelvic Examination (if indicated)

• External genitalia: Lesions, discharge 3
• Speculum examination: Cervical motion tenderness, discharge, bleeding 3
• Bimanual examination: Adnexal masses, tenderness, cervical motion tenderness 3

Critical pitfall: The absence of peritonitis on examination does not exclude bowel ischemia—patients often lack peritoneal signs despite established ischemia 1, 2

Laboratory Tests

Mandatory Initial Tests

Beta-hCG testing is mandatory in all women of reproductive age before any imaging 1, 4

Standard Laboratory Panel

• Complete blood count: Evaluate for leukocytosis suggesting infection or inflammation 1, 2, 4
• Comprehensive metabolic panel: Including liver function tests to evaluate hepatobiliary pathology 4
• Urinalysis: Evaluate for urinary tract infection or nephrolithiasis 4
• Serum lipase: More specific than amylase for pancreatitis 4

Additional Tests Based on Clinical Suspicion

• C-reactive protein: Superior sensitivity and specificity compared to white blood cell count for ruling in surgical disease 1, 2
• Lactate: Elevated suggests ischemia or sepsis, but normal levels do not exclude internal herniation or early ischemia 1, 2
• Blood cultures: If fever present and sepsis suspected 4
• D-dimer: If mesenteric ischemia suspected 2, 4

Critical pitfall: Normal laboratory tests in elderly patients do not exclude serious infection; many laboratory tests are nonspecific and may be normal despite serious infection 5, 1, 2

Imaging Studies

Initial Imaging Algorithm by Clinical Presentation

For premenopausal women with lower abdominal pain and concern for gynecologic pathology:

• Initial imaging: Transvaginal ultrasound is useful if there is clinical concern for acute gynecologic cause 5

For suspected non-gynecologic lower abdominal pain:

• CT abdomen and pelvis with IV contrast is the optimal initial imaging choice for acute nonlocalized abdominal pain, particularly when fever is present or serious pathology is suspected 5, 1, 2
• CT has 98% diagnostic accuracy for diverticulitis and allows risk-stratification for operative versus nonoperative treatment 5

For right lower quadrant pain (suspected appendicitis):

• Abdominal ultrasound is the most appropriate initial imaging method 1, 2
• CT abdomen and pelvis with contrast if ultrasound is inconclusive 2

For right upper quadrant pain (suspected cholecystitis):

• Ultrasound is the initial imaging test of choice 1, 2, 4

For suspected kidney stones:

• Non-contrast CT abdomen and pelvis 1, 2

Critical consideration: CT should be used judiciously in female patients of childbearing age after gynecologic etiologies have been clinically or sonographically excluded 5

Avoid: Conventional radiography has limited diagnostic value in most patients with abdominal pain and should not be routinely ordered 1, 2, 4

Assessment and Plan

Document Clinical Decision-Making

• Working diagnosis based on history, physical examination, laboratory results, and imaging 3
• Differential diagnoses to consider, including life-threatening causes: ectopic pregnancy, appendicitis, ovarian torsion, mesenteric ischemia, bowel perforation 7, 3
• Disposition: Admission versus outpatient management with close follow-up 5, 8
• Consultations: Surgery, gynecology, interventional radiology as indicated 5, 8

Red Flags Requiring Urgent Evaluation

Document presence or absence of:

• Severe pain out of proportion to physical findings (suggests mesenteric ischemia) 1, 2
• Signs of peritonitis (rigid abdomen, rebound tenderness) 2
• Hemodynamic instability (suggests bleeding or sepsis) 2
• Fever with abdominal pain (suggests infection or abscess) 5, 2
• Positive pregnancy test with abdominal pain (ectopic pregnancy until proven otherwise) 4, 3