Pelvic Pain Evaluation Note

Date/Time: [Date and time of encounter]

Setting: [clinic / ED / urgent care / consult]

Patient Age: [Age]

Relevant Anatomy: [Reproductive anatomy and prior pelvic/abdominal surgeries relevant to presentation] (State uterus/ovaries present or absent; include key surgeries with laterality if relevant.)

Pregnancy Capability: [yes / no / unknown] (If no, state reason: contraception method, sterilization, no uterus, not sexually active with sperm-producing partner, or other.)

Interpreter Used: [yes / no] (If yes, include language and interpreter name or ID.)

History Source: [patient / caregiver / records / multiple] (Note any limitations to history quality or completeness.)

Chief Complaint

[Patient-stated reason for visit in their own words, including pain location/laterality and time course if stated]

History of Present Illness

[Opening narrative establishing onset, time course, key pain features, what prompted today's visit, and relevant context such as recent activities, procedures, or illnesses] (Characterize as acute, subacute, chronic ≥6 months, or acute-on-chronic.)

Pain Characterization

• Location: [Midline / unilateral left / unilateral right / bilateral; superficial vs deep; specific regions]
• Radiation: [Radiation pattern, or none]
• Quality: [cramping / sharp / burning / pressure / electric / aching / other]
• Severity: [Current 0–10], peak [0–10]
• Timing/Pattern: [Cyclicity and triggers] (Include relation to menses, intercourse, bowel/bladder function, physical activity; frequency, duration, and progression.)
• Aggravating factors: [Factors worsening pain]
• Relieving factors: [Positions, self-care measures, medications, or therapies that help]

Associated Symptoms

• Pregnancy-related: [Missed period, breast tenderness, nausea, other] (Include only if reported.)
• Infection indicators: [Fever, chills, malaise]
• Gynecologic: [Abnormal bleeding, discharge, dyspareunia, dysmenorrhea, postcoital bleeding]
• Urinary: [Dysuria, urgency, frequency, hematuria, flank pain]
• Gastrointestinal: [Constipation, diarrhea, bloating, hematochezia, melena, nausea, vomiting]
• Red flags: [Syncope, presyncope, shoulder pain, sudden severe onset, hemodynamic symptoms]

Safety Screening

(Document explicit yes/no/unknown for each. If any time-critical concern is positive, document immediate actions in Plan.)

• Pregnancy possibility: [yes / no / unknown] (If no, reason: effective contraception, sterilization, no uterus, not sexually active with sperm-producing partner, or other.)
• Severe bleeding with hemodynamic symptoms: [yes / no / unknown]
• Fever or systemic illness: [yes / no / unknown]
• Sudden severe unilateral pain: [yes / no / unknown]
• Postmenopausal or postcoital bleeding: [yes / no / unknown]
• Recent uterine instrumentation or postpartum status: [yes / no / unknown] (Include timing if yes.)
• STI exposure risk factors: [yes / no / unknown] (Briefly note risk factors if yes.)

Focused History

(Include elements relevant to the presentation.)

• Menstrual history: LMP [date], cycle [length/regularity], flow [light / moderate / heavy], dysmenorrhea [severity], contraception [type and adherence], IUD [type and placement date if present]
• Pregnancy/obstetric history: [Gravida/Para], [current pregnancy status if applicable], [fertility intentions if relevant to treatment decisions]
• Sexual history and dyspareunia: [Entry vs deep pain, cycle relationship, lubrication issues, vestibular symptoms, impact on intimacy] (Introduce with permission-seeking language; document partners, protection, STI history as relevant.)
• Endometriosis screening: [Cyclical pain affecting function, deep dyspareunia, cyclical bowel/bladder symptoms, infertility concerns, family history]
• Prior episodes: [Previous evaluations and key results, treatments tried and responses, prior imaging or procedures]

Past Medical and Surgical History

(Prioritize conditions relevant to pelvic pain differential. Document unknown but relevant history as "unknown—will obtain.")

• Gynecologic: [Endometriosis, fibroids, PID, prior STIs, ovarian cysts]
• Urinary: [Kidney stones, UTIs, bladder pain syndrome]
• Gastrointestinal: [IBS, IBD, diverticular disease]
• Chronic pain/MSK: [Fibromyalgia, chronic pain syndromes, back conditions]
• Pelvic/abdominal surgeries: [Procedure type, year, laterality if applicable]

Medications and Allergies

• Current medications: [Medication list with doses] (Emphasize hormonal therapies and analgesics.)
• Allergies: [Drug and reaction type] (Note especially antibiotics and NSAIDs.)

Social History

(Include elements that affect today's plan.)

• Substance use: [Tobacco, alcohol, other substances relevant to pain management]
• Safety: [Safety concerns if clinically appropriate to assess]
• Functional impact: [Effect on work, school, sleep, daily activities]
• Mental health: [Relevant comorbidities or trauma history, especially for chronic pain presentations]

Review of Systems

(Focused review limited to systems informing the differential.)

• Constitutional: [Fever, chills, weight change, fatigue]
• Genitourinary: [Bleeding, discharge, urinary symptoms]
• Gastrointestinal: [Nausea, vomiting, bowel changes, rectal bleeding]
• Musculoskeletal/Neurologic: [Back or hip pain, weakness, numbness]

Physical Examination

Vital signs: T [temp], HR [rate], BP [pressure], RR [rate], SpO2 [percent], Pain [0-10]

General: [Appearance, distress level, toxicity assessment]

Abdominal Examination

• Inspection: [Distension, scars, visible abnormalities]
• Auscultation: [Bowel sounds present / absent / hyperactive / hypoactive]
• Palpation: [Tenderness location with laterality and severity, presence/absence of guarding and rebound]
• Peritoneal signs: [present / absent]
• CVA tenderness: [present / absent, laterality] (Include when urinary etiology considered.)
• Abdominal wall maneuvers: [Carnett sign or other tests and results if performed]

Pelvic Examination

Pre-exam: Consent [obtained], chaperone [offered and present / offered and declined / not offered—reason], positioning modifications [if any]

(If exam deferred or declined, document reason and alternative evaluation plan, then omit exam findings below.)

• External inspection: [Lesions, erythema, atrophy, discharge, tenderness]
• Speculum exam: [Vaginal mucosa, discharge character, cervical appearance, bleeding, samples obtained]
• Bimanual exam: [Cervical motion tenderness present/absent], [uterine size, position, tenderness], [adnexal findings with laterality], [pain reproducibility]
• Pelvic floor assessment: [Tone, trigger points, levator tenderness] (Prioritize for dyspareunia or chronic pain.)
• Cotton swab mapping: [Allodynia locations and severity] (Include if vulvar pain suspected.)
• Rectovaginal exam: [Nodularity, tenderness, uterosacral findings] (Include if deep endometriosis suspected and acceptable to patient.)
• Exam tolerance: [Patient tolerance, whether limited by pain]

Musculoskeletal Examination

(Include for chronic pain or unclear etiology.)

• [Back, SI joint, pubic symphysis tenderness]
• [Hip ROM and provocative tests if indicated]

Diagnostics

(Summarize key findings; do not paste full reports.)

Point-of-care: Pregnancy test [positive / negative], urinalysis [results]

Laboratory: [CBC, inflammatory markers, GC/CT NAAT, urine culture, other relevant results with values]

Imaging: [Modality], indication [reason], findings [key results and impression], comparison [to prior if relevant]

Pending: [Tests pending with follow-up plan]

Not obtained: [Tests not performed and rationale] (Include tests declined by patient with reason.)

External records: [Source, date, relevant findings]

Assessment

Summary: [Synthesis of patient context, time course, key positive and negative findings, highest-risk considerations addressed, and working diagnostic category—acute vs chronic, gynecologic vs nongynecologic vs multisystem]

Differential Diagnosis

Time-critical considerations: [Diagnosis with brief for/against reasoning for each]

Other considerations: [Diagnosis with brief for/against reasoning for each]

Working diagnoses: [Standardized terms; use "suspected" when not confirmed] (Document diagnostic uncertainty and what would confirm or refute.)

Plan

(Organize by problem from highest to lowest acuity.)

[Problem 1: Diagnosis or syndrome]

• Diagnostics/Monitoring: [Tests ordered, imaging strategy with pregnancy awareness, serial exams if indicated]
• Therapeutics: [Medications with doses, procedures, non-pharmacologic measures]
• Referrals: [Specialties and urgency]
• Education/Shared decision-making: [Options discussed, patient preferences, how plan aligns with goals]
• Follow-up: [Timeframe and modality], return precautions [warning signs tailored to leading risks]

[Problem 2: Diagnosis or syndrome]

(Follow same structure as above. Add additional problems as needed.)

Acute Presentation

(Include if applicable.)

• Disposition: [discharge / observation / admit / transfer] with rationale
• Empiric treatment and response: [Therapy given and immediate response]
• Imaging rationale: [Modality chosen considering pregnancy status]
• Return precautions: [Worsening unilateral pain, syncope, fever, heavy bleeding, other specific risks]

PID Evaluation

(Include if PID suspected.)

• Minimum clinical criteria: [met / not met] with findings
• STI testing: [Tests obtained]
• Antibiotic regimen: [Regimen and duration if treated]
• Partner management: [Counseling provided / deferred]
• Hospitalization criteria: [met / not met] with rationale

Suspected Endometriosis

(Include if endometriosis suspected.)

• Symptom pattern: [Summary and functional impact]
• Exam findings: [suggestive / normal] (Normal exam does not exclude diagnosis.)
• Imaging plan: [Modality and purpose]
• Initial therapy: [Analgesic strategy, hormonal options discussed, expectations]
• Fertility considerations: [How fertility priorities influence treatment]
• Referral plan: [Gynecology, pelvic pain specialist, or surgical considerations]

Dyspareunia/Vulvovaginal Pain

(Include if applicable.)

• Pain phenotype: [Entry vs deep, cycle relation, vestibular findings]
• Exam approach: [Modifications used for patient comfort]
• Pelvic floor: [Findings and PT referral plan]
• Contributing factors: [Management for atrophy, infection, or other factors]

Chronic Pelvic Pain Management

(Include if chronic pain ≥6 months.)

• Multimodal plan: [Pelvic floor PT, behavioral health, pain management, integrative approaches]
• Functional goals: [Activity, sleep, work targets]
• Symptom tracking: [Diary, app, or interval metrics]
• Testing approach: [Avoid repetitive low-yield testing; criteria for escalation]
• Red flags for escalation: [Specific warning signs relevant to this case]

Follow-up and Safety Netting

• Follow-up: [in-person / telehealth] in [timeframe]
• Pending results: [Communication plan for outstanding tests]
• Return precautions: [Warning signs tailored to highest-risk differentials under consideration]
• Work/school documentation: [Provided / not needed]