Patient History

"Where is the pain?"

• Whole abdomen

• Upper Abdomen

• Lower Abdomen

• Right Lower Quadrant

• Left Lower Quadrant

• Suprapubic area

• Different places at different times

"Did the pain start suddenly (within a few minutes) or gradually (over hours or days)?"

• Suddenly

• Gradually

How long has the pain lasted?

• Hours

• Days

• Months

How intense is the pain?

• Mild

• Moderate (Interferes with some activities)

• Severe (Unable to function without extreme effort)

Is the pain constant?

• Constant

• Cramping

• Intermittent

Is the pain getting worse?

• Worse and worse

• Better and better

• Unchanging

Pain throughout the whole abdomen favors moderate to severe PID, ruptured ectopic pregnancy, gastroenteritis and functional bowel syndrome

Upper abdominal pain makes any gynecologic diagnosis unlikely, while lower abdominal pain makes a gynecologic diagnosis (PID, endometriosis, degenerating fibroids, etc.) more likely.

Right lower quadrant pain increases the likelihood of appendicitis, ectopic pregnancy, ovarian cyst, mittelschmerz and pyelonephritis, but diminishes the likelihood of diverticulitis.

Left lower quadrant pain favors an ovarian cyst, ectopic pregnancy, pyelonephritis, and diverticulitis, but makes appendicitis very unlikely.

Suprapubic pain favors cystitits, PID, abortion, endometriosis, dysmenorrhea, degenerating fibroid, gastroenteritis and functional bowel syndrome.

Pain moving to different places at different times is characteristic of such GI problems as gastroenteritis and functional bowel syndrome, and is very uncharacteristic of any gynecologic problem.

Sudden onset of pain is typically seen in ruptured ectopic pregnancy, ruptured or torsioned ovarian cysts, mittelschmerz, renal colic, gastroenteritis and functional bowel syndrome.

If the pain has lasted for months, it is unlikely to be from appendicitis, ectopic pregnancy, gastroenteritis or renal colic.

Mild pain favors mild PID, threatened abortion, ovarian cyst, cystitis, mittelschmerz, dysmenorrhea, endometriosis, degenerating uterine fibroid, infected/rejected IUD, gastroenteritis and functional bowel syndrome. It makes renal colic unlikely.

Moderate pain (interferes with some activities) can be seen with all gynecologic diagnoses, appendicitis, functional bowel syndrome, gastroenteritis, and pyelonephritis.

Severe pain (unable to function without extreme effort) can be caused by moderate-severe PID, ruptured ectopic pregnancy, abortion, labor, torsioned ovarian cysts, pyelonephritis, renal stones, degenerating uterine fibroids, infected/rejected IUD, gastroenteritis, bowel obstruction, and diverticulitis. This degree of pain is not often seen in ruptured ovarian cysts, cystitis or endometriosis.

Cramping indicates the rhythmic contractions of smooth muscle, such as is found in bowel, uterus, and ureter. Appendicitis may be both cramping and constant, as is diverticulitis. PIDmay also cause constant pain (from stretching and inflammation of the peritoneum) and cramping (from local irritation of the bowel).

Progressive pain points towards more serious problems (appendicitis, ovarian torsion, moderate-severe PID, sepsis, etc.) and toward a deteriorating clinical condition. Pain that is steadily improving often requires no intervention at all.

How's your appetite?

• Decreased

• Increased

• Normal

Are you nauseated?

• Yes

• No

Have you vomited?

• Yes

• No

Nausea (feeling sick to your stomach) and loss of appetite are characteristic of such GI problems as appendicitis, bowel obstruction, diverticulitis, gastroenteritis, and those other conditions that stimulate the peritoneum or otherwise provoke a vagal stimulation. Among these are torsioned ovarian cysts, ruptured ectopic pregnancy and moderate-severe PID.

Presence of a normal appetite or increased appetite are favorable signs that whatever has caused the pain is either of a mild nature or is resolving.

Vomiting is associated with appendicitis, gastroenteritis, and bowel obstruction.

How are your bowel movements?

• Normal

• Constipated

• Diarrhea

• Bloody

• Mucousy

Normal BMs speak against gastroenteritis, diverticulitis, functional bowel syndrome and bowel obstruction.

Constipation is seen in bowel obstruction, functional bowel syndrome, and not often seen in gastroenteritis or diverticulitis. There is a symptoms, tenesmus, in which the patient describes the sensation that if she could just have a good bowel movement, the pain would be relieved. Tenesmus can be seen in any acute process in the pelvis, but is characteristic of diverticulitis.

Diarrhea is associated with gastroenteritis, diverticulitis and functional bowel syndrome. Bloody and mucousy diarrhea is seen usually associated with diverticulitis, but can also be seen in functional bowel syndrome.

Is your urination normal?

• Painful

• Frequent

• Bloody

• Normal

The presence of urinary symptoms directs your attention to such conditions as cystitis, pyelonepritis and renal stones.

Cystitis usually provokes frequent, painful urination, and occasionally bloody urine. The absence of these symptoms makes cystitis very unlikely.

pyelonephritis can have the same symptoms as cystitis, but also kidney pain. Not all cases of pyelonepritis have these lower urinary tract symptoms, however.

With renal colic due to ureteral stones, the only lower urinary tract symptom typically seen is hematuria, unless there is a superimposed infection.

How do you feel?

• Lightheaded

• Cannot be upright

• Doesn't feel faint

Feeling lightheaded is caused by inadequate cerebral perfusion, such as is seen in hypovolemia (bleeding, dehydration), or strong vagal stimulation (diarrhea, stretching of the peritoneum).

If she cannot be upright without losing consciousness, this is a symptom of severe hypovolemia, such as might be seen in a ruptured ectopic pregnancy.

Right shoulder pain is:

• Present

• Absent

Right shoulder pain usually indicates irritation of the undersurface of the right hemi-diaphragm and consequent stimulation of the phrenic nerve with referred pain to the right shoulder.

This can be seen with significant hemoperitoneum (ruptured tubal ectopic pregnancy, sometimes ruptured ovarian cysts), free air (ruptured diverticulum or appendix), or pus (moderate-severe PID).

The pain is worse with:

• Coughing

• Moving

• Eating

• Nothing

• Other

Pain that worsens with coughing or moving suggests peritoneal irritation, such as is seen in appendicitis, PID, ruptured ovarian cyst or ectopic pregnancy, torsed ovarian cyst, diverticulitis and bowel obstruction.

Pain that worsens with eating points towards GI problems (gastroenteritis, diverticulitis, functional bowel syndrome or bowel obstruction) as its' cause.

The pain improves with:

• Lying still

• Antacids

• Eating

• Nothing

• Other

Most abdominal and pelvic pain from any cause will improve with rest.

Antacids are helpful only for upper GI distress, such as is seen in gastritis, esophagitis, or duodenitis.

Eating improves esophagitis (heartburn) briefly as it buffers the chemical burn in the lower esophagus.

Has this happened before?

• Yes

• No

Past medical history?

• Functional bowel syndrome

• Diverticular illness

• Other

Prior history can provide insight into the current condition. Problems such as dysmenorrhea, endometriosis, mittelschmerz, and diverticular disease and functional bowel syndrome tend to have recurrent symptoms.

Past surgical history:

• None

• Appendectomy

• Bowel resection

• Tubal Ligation

• Ectopic pregnancy

• Hysterectomy

• One tube or ovary

• Both ovaries

• Negative laparoscopy in the last two years

Women with a previous  bowel resection are at increased risk for having bowel obstruction.

Those with a history of tubal ligation or hysterectomy are very unlikely to have a pregnancy or pregnancy problems. They are at decreased risk of endometriosis.

Those with a history of ectopic pregnancy are at increased risk of having another ectopic pregnancy.

Negative laparoscopy within the last 2 years decreases the chance of endometriosis and uterine fibroids.

Past gynecologic history:

• Cystitis

• Pyelonephritis

• Ovarian Cyst

• Endometriosis

• PID or some STD

• Deep dysparunia

• Dysmenorrhea

• Fibroids

• None

• Other

A history of cystitis or pyelonephritis increases the risk for future cystitis and pyelonephritis.

Prior history of ovarian cyst increases the likelihood of future ovarian cysts. The same is true for PID, and endometriosis.

Painful intercourse on deep penetration is associated with appendicitis, PID, ectopic pregnancy, ovarian cyst, endometriosis and degenerating uterine fibroids.

Moderate to severe menstrual cramps are seen with endometriosis and degenerating uterine fibroids.

Contraceptive History:

• Previous IUD

• Current IUD

• Current OCPs - skips some

• Current OCPs - never skips

• Other hormonal contraceptive

• Other

• Using no contraception or seeking a pregnancy

• No need for contraception

Current and previous IUD use increases the risk of PID. Current IUD use of the IUD decreases the risk of pregnancy, but if a pregnancy is present, increases the risk that the pregnancy will be an ectopic pregnancy.

Current use of OCPs (without skipping pills) and other hormonal contraceptives very much decreases the chance of a pregnancy-related problems. They also protect to some extent against ovarian cysts, PID, mittelschmerz, dysmenorrhea, and endometriosis.

Unless the patient is not sexually active, failing to use contraception or active seeking of a pregnancy increases the chance that her pain is due to a pregnancy-related problem.

Sexual History:

• Never had intercourse

• No intercourse since her LMP

• No intercourse in the last 3 months

• Other

If the patient has never had intercourse or a "near intercourse experience," then pregnancy-related problems, STDs, cystitis and pyelonephritis are very unlikely. Some patients have very good recollections of this issue and others are more forgetful.

A woman who has not had intercourse in the last 3 months is not very likely to have PID(it would have shown up earlier) or a tubal ectopic pregnancy (it would have already ruptured).

When did your last normal menstrual  begin?

Problems associated with menses include dysmenorrhea, endometriosis, ruptured ovarian cysts, and PID. The pain can begin just before menses and continue throughout menses.

Mid-cycle pain is characteristic of mittelschmerz.