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III. HISTORY
TOPIC OUTLINE • A thorough history is very important
I. Pelvic Mass • Last menstrual period
II. Potential Sources of pelvic mass • Menstrual irregularities
III. History o Normal menstrual cycle: 21-35 days
IV. Pelvic Exam • Pain
V. Diagnostic Test o Character
VI. Gynecological Cause of pelvic mass o Frequency
A. Ovarian o Location
1. Benign Ovarian Masses • Gastrointestinal symptoms
a. Functional Cyst • Urinary bowel changes
b. Benign Ovarian Tumors • Fever
2. Malignant Ovarian Tumors - Important in determining if mass is infectious
3. Pelvic Inflammatory Disease • Weight loss
4. Endometriosis - Possibility of malignancy
B. Uterine • OB/ GYNE History
1. Myoma/Leiomyoma • Gravidity/ parity
2. Adenomyosis • Details of obstetric history
3. Endometrial Polyp - Number of pregnancies, abortions
4. Uterine Cancer • Pelvic surgery
5. Hematometra • Pelvic infection
• Menstrual history
I. PELVIC MASS • Previous Pap smear history
- Mass in the pelvis diagnosed by physical examination or found • Urinary history
incidentally during diagnostic imaging studies • Frequency
- Pelvic masses might not be only gynecologic in nature so when a • Hematuria
female patient comes to ER complaining with a pelvic mass, we • Incontinence
don’t know if she is a patient of gyne or surgery. • Voiding pattern
• Gastrointestinal
II. POTENTIAL SOURCES OF PELVIC MASS • Increased girth as the size of the mass increases
- Any structure in or abutting the pelvis may be the source of • Nausea/ Vomiting
enlargement, distention or neoplasia, resulting in the • Bowel dysfunction
formation of a mass • Tarry stools/ blood in stools
1. Central nervous system • Diarrhea/Constipation
• Meningocele • Vascular
2. Urinary tract • Known aneurysm or hemangioma
• Pelvic kidney • Developmental
• Neurogenic bladder • Congenital anomalies
• Bladder malignancy • Neurologic motor problems
• Interview patient first in ER to make thorough history if • Past history
this is a gynecologic pathology before referring the • Stroke, diabetes, medication, malignancy
patient. • Family history
3. Vascular / lymphatic • Diabetes, malignancy
• Hemangioma IV. PHYSICAL EXAM
• Aneurysm A. Abdomen
• Lymph node enlargement • Inspection - scar, abdominal enlargement
4. Gastrointestinal • Auscultation - bowel sounds
• Appendiceal abscess • Percussion
▪ Patient with high tolerance to pain might not go • Palpation – Mass (Characterize), tenderness, guarding, fluid
or seek medical attention wave, assess size of abdominal organs
• Diverticular abscess B. Pelvis
• Gastrointestinal tumors or malignancy • Inspection
5. Retroperitoneal/ Peritoneal Masses • Speculum examination
• Peritoneal inclusion cyst • Internal examination/bimanual examination
• Retroperitoneal mass – fibrosarcoma - Internal examination: 2 examining fingers are
• Endometriosis implants inserted to the introitus
6. Reproductive Organs - Bimanual examination: one examining finger is inside
• Pregnancy - In or out of uterus the introitus while the other hand is placed on the
▪ If patient is in the reproductive age group, we abdomen
cannot discount the possibility of pregnancy • Rectovaginal examination
even if the patient claims she has no history of - Once done with the
sexual contact. internal examination,
• Cervical mass – benign or malignant insert the middle
• Uterine mass – benign or malignant
3. Endometrial polyp
Figure 2: Enlarged ovary to show a cystic cavity filled with old blood - Localized overgrowths of endometrial glands and stroma
typical of endometriosis that project beyond the surface of endometrium
- Wide range of bleeding pattern
B. UTERINE o Menorrhagia
1. Myoma/ Leiomyoma o Premenstrual and postmenstrual spotting
- Sharply circumscribed, discrete, round, firm gray-white • Polyp not responsive to hormonal treatment so management is
tumors varying in size from small nodules to massive tumors polypectomy.
that fill the pelvis
- Submucous, intramural, subserous
Figure 3: Submucosal, intramural and subserosal leiomyomata
Figure 5: Uterus:
Opened anteriorly
through the cervix and
into the endometrial
cavity
T|F|F|T|F|T.
G.F.D.E.H.B.C
!
b.Transverse vaginal septum
- Hymen is open but there’s something blocking
the vaginal canal
c. Previous gynecologic procedures – Scarring
• Clinical presentation
- Cyclic pain
- Amenorrhea
- Abdominal pain mimicking acute abdomen
- Difficulty with urination or defecation
SUMMARY
Complete history
Physical exam
Diagnostic tests