The patient is a 65 year old woman with a three-day history of increasing abdominal distention, no bowel movement and minimal flatus. Laxatives, Fleets enema and magnesium citrate had no effect. The oral magnesium citrate resulted in vomiting.

PAST GYN HISTORY: no hormone-replacement therapy, last pelvic examination and ultrasound 1-1/2 years ago with no evidence of mass

PAST OB HISTORY: Gravida 4, para 4-0-0-4 with four normal spontaneous vaginal deliveries.

PHYSICAL EXAMINATION:
VITAL SIGNS: Afebrile, vitals stable
HEENT: Within normal limits. No thyromegaly. No lymphadenopathy.
CHEST: Clear to auscultation bilaterally.
CARDIOVASCULAR: Regular rate and rhythm. No murmur, rub, or gallop.
ABDOMEN: Moderately distended, diffusely tender, no bowel sounds present, tympanitic to percussion.
EXTREMITIES: No cyanosis, clubbing, or edema, non-tender.
GU: Bimanual exam fullness in the left adnexal region, decreased mobility of the uterus.

LABORATORY DATA: white blood count of 17,000; hematocrit 45.3%, platelets 474,000; 85% PMNs. Sodium 130, potassium 3.0, chloride 88, bicarbonate 30, BUN 5, creatinine 0.5, glucose 216, calcium 8.6, AST 35, ALT 21, total protein 6.9, albumin 2.9, alkaline phosphatase 303. Urinalysis: Positive nitrites, bacteria, white blood cells, and mucus.

1. What is your differential diagnosis?

2. What other testing do you want?