I have seen a patient with complain of right lower abdominal swelling in gynaecology ward. How can I approach this patient through history and examination wise with ruling out each and every gynaecological and non gynaecological cause of lower abdominal swelling . Plz give me best format for history taking for MBBS student which contain all causes .

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Approach to a Patient with Right Lower Abdominal Swelling in Gynaecology Ward

STRUCTURED HISTORY FORMAT FOR MBBS STUDENTS

PART 1: HISTORY TAKING

A. BIODATA

Parameter	Details to Note
Name	-
Age	Crucial - reproductive age vs. postmenopausal changes differential
Marital status	Married / unmarried / widowed
Parity	Gravida, Para, Abortus (G_P_A_)
Occupation	-
Address	-
Referred by	-
Date of admission	-

Why age matters:

Child (<10 yrs): Wilms' tumor, sacrococcygeal teratoma, ovarian cyst
Adolescent (10-20 yrs): Ovarian teratoma, functional cyst, appendicular mass
Reproductive age (20-45 yrs): Ectopic pregnancy, fibroid, ovarian cyst, PID, appendicular lump
Perimenopausal / Postmenopausal: Ovarian cancer, colonic carcinoma, uterine malignancy

B. CHIEF COMPLAINT

"Swelling in the right lower abdomen since ______ (duration)"

Ask:

Onset - sudden or gradual?
Duration - days / weeks / months / years
Progression - increasing, static, or decreasing in size?
Character - painful or painless?

C. HISTORY OF PRESENT ILLNESS (HPI)

1. SWELLING (LUMP) - LOPD + CHARACTERS

Location - right lower quadrant, right iliac fossa (RIF), right lumbar, hypogastric?
Onset - sudden (torsion, ectopic rupture) vs. gradual (fibroid, ovarian cyst, malignancy)
Progression - rapid growth (malignancy) vs. slow (fibroid, dermoid)
Duration
Size - roughly? (growing, stable)
Consistency felt by patient - hard, soft, fluctuant?
Relation to menstrual cycle - increases premenstrually? (endometrioma, fibroid)
Any change in size during pregnancy, after menopause?

2. PAIN

Site - RIF, RLQ, hypogastric, radiating to thigh or back?
Onset - acute (torsion, ruptured ectopic) vs. chronic (fibroid, endometriosis)
Character - colicky (torsion, ectopic), dull aching (fibroid, ovarian cyst), burning (PID), crampy
Radiation - to shoulder tip (diaphragmatic irritation - ruptured ectopic), to back (ureteral colic, psoas abscess), to thigh (nerve compression)
Severity - VAS score 1-10
Aggravating/Relieving factors
Association with menses - dysmenorrhea (endometriosis, fibroid)
Cyclical nature? (corpus luteum cyst)

3. MENSTRUAL HISTORY (MH) - THE GYNAECOLOGICAL CORNERSTONE

LMP (Last Menstrual Period) - Date, character (normal or abnormal)
Age of menarche - (normal 11-14 years)
Cycle - regularity (regular / irregular), frequency (days), duration of flow (days) e.g., 28/5
Amount of flow - number of pads/day, clots? (heavy = menorrhagia - suggests fibroid)
Dysmenorrhea - primary or secondary? (secondary - endometriosis, fibroid, PID)
Intermenstrual bleeding (IMB) - between periods? (cervical/endometrial pathology)
Postcoital bleeding (PCB) - after intercourse? (cervical carcinoma)
Postmenopausal bleeding (PMB) - after menopause? (endometrial/ovarian malignancy)
Amenorrhea - primary or secondary? (pregnancy, hormonal causes)
Oligomenorrhea - PCOS?
Menopausal status - if postmenopausal, since when?

4. OBSTETRIC HISTORY

Total pregnancies (G_P_A_L_)
Any ectopic pregnancy in the past?
Any miscarriages or abortions? (PID risk after abortion)
Mode of delivery - LSCS scar? (can cause endometriosis in scar)
Any complications during deliveries?

5. ASSOCIATED SYMPTOMS

Urinary symptoms:

Frequency, urgency, dysuria - (UTI, pelvic mass pressing on bladder)
Hematuria - (renal/bladder pathology, endometriosis)
Urinary retention - (large fibroid or ovarian cyst)
Urinary incontinence?

Bowel symptoms:

Constipation or change in bowel habits - (colonic mass, pelvic mass pressing on rectum)
Rectal bleeding / melena - (colorectal malignancy, endometriosis of bowel)
Tenesmus - (pelvic malignancy, rectal involvement)
Diarrhea - (PID, irritable bowel, Crohn's)

Systemic symptoms:

Fever with chills - (PID, tubo-ovarian abscess, appendicular abscess)
Loss of appetite (LOA) + Loss of weight (LOW) - (malignancy - "red flag")
Night sweats - (tuberculosis, lymphoma)
Nausea/Vomiting - (ovarian torsion, appendicitis, early pregnancy)
Fatigue + pallor - (chronic blood loss in fibroid, malignancy)
Ascites (abdominal fullness, fluid thrill) - (ovarian malignancy, peritoneal TB)

Vaginal discharge:

Amount, color (white/yellow/green/blood-stained)
Smell (offensive = infection)
Duration
Associated pruritus
PID, cervicitis, Trichomonas, Candida

6. SEXUAL HISTORY (Sensitive - ask respectfully)

Sexually active?
Number of partners (PID risk factor)
Use of contraception - IUD? (increased PID risk), OCP? (reduces ovarian cyst risk)
Dyspareunia (pain during intercourse) - (PID, endometriosis, ovarian cyst)
Any STI history?

D. PAST HISTORY

Previous similar episodes?
Any previous abdominal/pelvic surgery? (adhesions, previous ectopic, myomectomy scar, appendicectomy)
Any history of tuberculosis (TB) - genital TB causes adnexal mass
Malignancy - previous cancer elsewhere (metastatic disease)
Inflammatory bowel disease (Crohn's - right iliac fossa mass!)
Urinary tract infections
Any hospitalization?

E. FAMILY HISTORY

Ovarian cancer (BRCA1/BRCA2 mutation risk)
Breast cancer
Colorectal cancer (Lynch syndrome)
Diabetes, hypertension

F. PERSONAL HISTORY

Diet - vegetarian / non-vegetarian (nutritional status)
Bowel & bladder habits
Sleep
Addiction - smoking (cervical cancer risk), alcohol
Exercise habits
Marital/sexual history (as above)

G. CONTRACEPTIVE HISTORY

Current method of contraception
Combined OCP - reduces functional ovarian cysts
Progestin-only pill
IUCD/IUD - increases PID risk
Tubal ligation (previous sterilization)
Barrier methods

H. TREATMENT HISTORY

Any current medications? (hormonal therapy, anticoagulants)
Any previous hormone therapy (HRT)?
Previous treatment for present complaint?
Allergies?

PART 2: PHYSICAL EXAMINATION

A. GENERAL EXAMINATION (HEAD TO TOE)

System	What to Look For	Significance
Built & Nourishment	Cachexia, muscle wasting	Malignancy
Pallor	Conjunctival pallor	Chronic blood loss (fibroid), malignancy
Icterus	Yellowish sclerae	Liver metastasis, hemolysis
Cyanosis	-	Cardiorespiratory cause
Lymphadenopathy	Left supraclavicular (Virchow's node), inguinal	Lymphoma, metastatic cancer
Edema	Pedal edema	Hypoproteinemia (malignancy), venous compression
Vitals	BP, Pulse, Temperature, RR	Tachycardia/hypotension = ruptured ectopic (shock!), fever = PID
Hirsutism / Acne	-	PCOS
BMI / Weight	Obesity	PCOS, endometrial cancer

B. ABDOMINAL EXAMINATION

1. INSPECTION

Contour of abdomen - flat, scaphoid, distended, globular
Site and shape of swelling - right iliac fossa, right lumbar, or extending to midline/hypogastric
Umbilicus - central or displaced (large mass displaces umbilicus)
Skin over swelling - redness (inflammation), visible veins (portal hypertension, IVC obstruction), scar marks
Movement with respiration - moves with respiration (hepatic/splenic/renal) vs. does not (pelvic mass)
Visible peristalsis - intestinal obstruction
Fullness in flanks - ascites (malignancy, peritoneal TB)
Surgical scars - Pfannenstiel scar (previous C-section/myomectomy), McBurney's scar (appendicectomy)

2. PALPATION

Superficial palpation first:

Tenderness, guarding, rigidity (peritonism = ectopic, appendicitis, torsion)
Skin temperature over swelling

Deep palpation:

Characteristics of lump:
- Site (RIF / RLQ / extending to midline)
- Size (in cm, e.g., 8x6 cm)
- Shape (spherical, irregular, lobulated)
- Surface (smooth = ovarian cyst, fibroid; nodular = malignancy, fibroid)
- Consistency (cystic/fluctuant = ovarian cyst; firm/rubbery = fibroid; hard/stony = malignancy)
- Tenderness (tender = PID, torsion, ectopic; non-tender = benign cyst, fibroid)
- Margins (well-defined = benign; ill-defined = malignancy, inflammatory mass)
- Mobility (mobile = ovarian cyst; restricted = malignancy, adherent inflammatory mass)
- Movement with respiration (pelvic masses are usually not moved by respiration)
- Reducibility (hernial swellings are reducible)
- Transillumination (cystic vs. solid)
- Can you get below the swelling? (Important - if you cannot get below = arises from pelvis)

Special palpation tests:

Uterine palpation - size, position, tenderness (enlarged = pregnancy, fibroid)
Ballotment of kidney - bimanual (renal mass vs. pelvic mass)
Fluid thrill, shifting dullness - ascites (ovarian malignancy)

3. PERCUSSION

Dullness over swelling (solid or cystic mass)
Resonance over swelling (bowel gas = intestinal mass)
Shifting dullness - ascites (ovarian cancer, peritoneal TB)
Liver dullness - hepatomegaly (metastasis)
Flanks - fluid in ascites

4. AUSCULTATION

Bowel sounds - normal, increased (intestinal obstruction), decreased/absent (peritonitis, ileus)
Bruit over mass - vascular tumors

C. PELVIC EXAMINATION (Per Vaginum / Per Speculum)

Obtain consent before pelvic examination. Only performed in sexually active patients.

Per Speculum (PS) Examination:

Vulva - lesions, discharge, condylomata
Vagina - rugosity, discharge, growths
Cervix - appearance (healthy pink = normal; strawberry = Trichomonas; ulcer/growth = carcinoma; cervical excitation tenderness = PID, ectopic)
OS - open or closed? (products of conception - spontaneous abortion)
Vaginal discharge - character, color, odor
Cervical motion tenderness (CMT) / Cervical excitation tenderness - hallmark of PID and ectopic pregnancy

Bimanual (Per Vaginum + Per Abdomen) Examination:

Uterus: Size (weeks of pregnancy equivalent), shape, consistency, mobility, position (anteverted/retroverted), tenderness
Adnexa (right and left): Fullness, mass, tenderness
Pouch of Douglas (POD): Fullness / bulge = hematoma (ruptured ectopic), pus (PID), mass (endometriosis nodules, malignancy)
Forniceal tenderness - PID, endometriosis

Per Rectum (PR) Examination (if indicated):

In virgins/unmarried patients as alternative to PV
Palpate rectovaginal septum - endometriosis nodules ("chocolate nodules")
Assess POD for masses
Rectal masses - colorectal carcinoma

PART 3: DIFFERENTIAL DIAGNOSIS FRAMEWORK

GYNAECOLOGICAL CAUSES

Cause	Key Features
Ectopic Pregnancy	Missed period, positive UPT, acute pain, cervical excitation tenderness, shock - EMERGENCY
Ovarian Cyst (functional, dermoid, endometrioma, serous/mucinous cystadenoma)	Gradual onset, cyclical relation, smooth, mobile, cystic swelling
Ovarian Torsion	Sudden severe colicky pain, nausea/vomiting, tender mass, emergency
Fibroid (Uterine Leiomyoma)	Heavy periods (menorrhagia), firm/rubbery, irregular lobulated mass, moves with uterus
Ovarian Carcinoma	Postmenopausal, solid/fixed, irregular, ascites, weight loss, family history
PID / Tubo-ovarian Abscess (TOA)	Fever, vaginal discharge, bilateral/unilateral adnexal tenderness, cervical excitation tenderness
Endometriosis / Endometrioma	Dysmenorrhea, dyspareunia, infertility, cystic mass (chocolate cyst), premenstrual exacerbation
Paraovarian / Paratubal Cyst	Mobile, separate from ovary, usually incidental
Hydrosalpinx / Pyosalpinx	History of PID, sausage-shaped adnexal mass
Genital TB	Low-grade fever, menstrual irregularity, infertility, history of TB contact
Cervical / Endometrial Carcinoma with parametrial spread	PMB, intermenstrual bleeding, growth on cervix
Uterine Prolapse	Prolapse symptoms, descent of mass on straining
Broad Ligament Fibroid	Moves with uterus, lateral to uterus

NON-GYNAECOLOGICAL CAUSES

Gastrointestinal:

Cause	Key Features
Appendicular Lump/Abscess	History of acute appendicitis, RIF mass, fever, tenderness at McBurney's point
Carcinoma Cecum/Ascending Colon	Elderly, weight loss, altered bowel habits, hard irregular mass, anemia
Crohn's Disease	Young, recurrent diarrhea, weight loss, cobblestone appearance on barium, skip lesions
Intestinal Tuberculosis	Night sweats, low-grade fever, history of pulmonary TB, right iliac fossa mass, ascites
Volvulus/Intussusception	Colicky pain, distension, obstruction features
Mesenteric Cyst	Fluctuant, mobile in all directions ("slips away")
Diverticulitis (uncommon on right)	Older age, bowel habit change, localized tenderness

Urological:

Cause	Key Features
Pelvic Kidney	On CT/IVP - right kidney in pelvis, no kidney in right lumbar region
Horseshoe Kidney	Bilateral lower pole fusion, incidental
Renal Mass / Wilms' Tumor	Child, hematuria, ballotable, bimanually palpable
Distended Urinary Bladder	Cannot get below, dull, midline, relieved by catheterization
Urachal Cyst	Midline, infraumbilical

Vascular:

Cause	Key Features
Iliac Artery Aneurysm	Pulsatile, expansile mass, elderly, atherosclerosis risk factors

Musculoskeletal / Wall:

Cause	Key Features
Hernia (inguinal, femoral)	Reducible, cough impulse, through inguinal or femoral canal
Spigelian Hernia	Lateral abdominal wall hernia
Rectus Sheath Hematoma	Post-trauma, anticoagulants, does not cross midline, no cough impulse
Psoas Abscess	Tender, fluctuant, RIF, loss of right lumbar lordosis, hip flexion deformity, TB spine
Lipoma / Sebaceous cyst	In abdominal wall, moves with skin
Desmoid Tumor	In abdominal wall, post C-section/laparotomy scar

Retroperitoneal:

Cause	Key Features
Retroperitoneal Lymphadenopathy	Lymphoma, TB, metastatic cancer, hard/firm, non-tender
Retroperitoneal Sarcoma	Fixed, deep, large
Sacrococcygeal Teratoma	Infants/young girls

Obstetric:

Cause	Key Features
Pregnancy (Uterus)	LMP, positive UPT, amenorrhea, soft cystic uterine enlargement
Ovarian Cyst in Pregnancy	Discovered incidentally during antenatal care

PART 4: KEY INVESTIGATIONS TO ORDER

Bedside / Rapid Tests:

Urine Pregnancy Test (UPT) - FIRST test in any woman of reproductive age with RIF swelling
Urine R/E - UTI, hematuria
Blood glucose, BP

Blood Tests:

CBC with differential - anemia (fibroid, malignancy), leukocytosis (PID, appendicitis)
ESR, CRP - inflammation (PID, TB, appendicitis)
LFT, RFT, serum electrolytes
Serum beta-hCG (quantitative) - ectopic pregnancy, gestational trophoblastic disease
Tumor markers:
- CA-125 - ovarian epithelial carcinoma (also elevated in endometriosis, PID)
- CA 19-9 - mucinous ovarian tumors, GI malignancy
- AFP + beta-hCG + LDH - germ cell tumors (young women)
- CEA - colorectal carcinoma
Coagulation profile - if bleeding diathesis suspected

Imaging:

Pelvic/Transvaginal Ultrasonography - FIRST-LINE imaging in gynecology
- Differentiates cystic vs. solid
- Identifies uterine vs. adnexal origin
- Free fluid in POD (ruptured ectopic, ovarian cyst)
- Doppler - vascularity (malignancy risk)
CT Abdomen & Pelvis - appendicular mass, renal/retroperitoneal, lymphadenopathy, staging of malignancy
MRI Pelvis - fibroid characterization, endometriosis, soft tissue masses
X-ray abdomen - calcifications in dermoid (teeth), fibroid (calcified), intestinal obstruction
IVP / CT Urogram - pelvic kidney, ureteral involvement

Special Tests:

Endometrial biopsy / D&C - if endometrial pathology
Pap smear - cervical carcinoma screening
High vaginal swab (HVS) + endocervical swab - PID, STIs
Culdocentesis - free fluid/blood in POD (ruptured ectopic)
Diagnostic laparoscopy - "gold standard" for endometriosis, ectopic pregnancy

PART 5: QUICK EMERGENCY RED FLAGS - DO NOT MISS

Red Flag	Think Of
Acute severe RIF pain + Amenorrhea + Shock	Ruptured Ectopic Pregnancy - EMERGENCY
Sudden severe pain + nausea/vomiting + tender mass	Ovarian Torsion - EMERGENCY
Fever + pelvic tenderness + vaginal discharge	PID / Tubo-Ovarian Abscess
RIF pain + anorexia + McBurney's tenderness	Appendicitis / Appendicular Lump
Postmenopausal + ascites + solid fixed mass	Ovarian Malignancy
Weight loss + altered bowel habits + hard RIF mass	Carcinoma Cecum / Colonic Ca
Child + RIF mass + hematuria	Wilms' Tumor
Fever + RIF mass + TB contact	Ileocaecal TB / Psoas Abscess

SUMMARY MNEMONIC FOR GYNAECOLOGICAL CAUSES OF RIGHT LOWER SWELLING

"ECHO-PET-GEF"

E - Ectopic pregnancy
C - Cyst (Ovarian - functional, dermoid, endometrioma, cystadenoma)
H - Hydrosalpinx / Hematosalpinx
O - Ovarian torsion / Ovarian carcinoma
P - PID / Pyosalpinx / Paraovarian cyst
E - Endometriosis (Chocolate cyst)
T - Tubo-ovarian abscess / TB (Genital)
G - Genital TB
E - Ectopic pregnancy (mentioned again as most dangerous)
F - Fibroid (Broad ligament / Subserosal)

This format covers all gynaecological and non-gynaecological causes systematically. In clinical practice, always start with UPT in any woman of reproductive age - Berek & Novak's Gynecology emphasizes that ruling out pregnancy is the single most important first step in any woman presenting with pelvic swelling.

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