Abdominal Pain in a Female

Introduction:

Good morning Miss. Smith I am Dr. XYZ, senior house officer in the department of obstetrics and gynaecology. I would like to have a small chat with you regarding your abdominal (tummy) pain, is that all right with you?

Current Complaint:

  • When did the pain start?
  • Could you point out exactly where the pain is?
  • Type of pain?
  • Is the pain radiating anywhere?
  • What makes the pain better and what makes it worse?
  • Is the pain getting better now?
  • Is there any diurnal variation (during the day)?
  • Associated feature like nausea, vomiting and distention?
  • Vomit colour and character? Relation to food?
  • Does it wake you up at night (severity)?
  • How is your appetite?
  • Any weight loss?
  • Are you opening your bowels regularly? Diarrhoea and constipation?
  • Stool formed? Is it hard to flush? Colour?
  • Relation to exercise? breathlessness and sweating?

Menstrual History:

  • When was the last period?
  • Are you on any contraceptives?
  • Could you be pregnant?
  • Burning micturition, any history of UTI and vaginal discharge?
  • Is the vaginal discharge foul smelling? Colour?
  • Have you had similar episode in the past?

Family History:

  • Bowel diseases or Carcinoma?

Smoking and alcohol? Drug history?

Medical History:

  • History of acid peptic disease, angina, appendicectomy, STD, PID, IUCD, ectopics.

Differential Diagnosis:

  • UTI, STD, PID, appendicitis, ectopic pregnancy, acid peptic disease, pancreatitis, renal and gall stones.

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