In military settings, tactical circumstances may limit the extent of evaluation of abdominal pain. Lab and imaging may not be possible at this moment, and the examiner may possess limited clinical skills in dealing with OBGYN issues.
That said, there is still much that can be done to reach a working diagnosis and begin effective therapy. Essential to this effort are these three lines of inquiry, each contributing to reaching a reliable clinical diagnosis:
- Vital Signs
- History (Ask the right questions.)
- Physical (Lower level physical exam skills, not higher level.)
Vital Signs
- Temperature
- Pulse
- Respirations
- Blood Pressure
Should you need additional guidance on obtaining accurate vital signs, help can be found here. (Taking Vital Signs)
History
Most healthcare providers will know many of the right questions to ask the patient. But there are some highly targeted questions that can prove very useful in clinically distinguishing the different causes of abdominal pain in women. They are listed below, but a downloadable single sheet is available here.
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 (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
How’s your appetite?
- Decreased
- Increased
- Normal
Are you nauseated?
- Yes
- No
Have you vomited?
- Yes
- No
How are your bowel movements?
- Normal
- Constipated
- Diarrhea
- Bloody
- Mucousy
Is your urination normal?
- Painful
- Frequent
- Bloody
- Normal
How do you feel?
- Lightheaded
- Cannot be upright
- Doesn’t feel faint
Right shoulder pain is:
- Present
- Absent
The pain is worse with:
- Coughing
- Moving
- Eating
- Nothing
- Other
The pain improves with:
- Lying still
- Antacids
- Eating
- Nothing
Has this happened before?
- Yes
- No
Past medical history?
- Functional bowel syndrome
- Diverticular illness
- Other
Past surgical history:
- None
- Appendectomy
- Bowel resection
- Tubal Ligation
- Ectopic pregnancy
- Hysterectomy
- One tube or ovary
- Both ovaries
- Negative laparoscopy in last 2 years
Past gynecologic history:
- Cystitis
- Pyelonephritis
- Ovarian Cyst
- Endometriosis
- PID or some STD
- Deep dysparunia
- Dysmenorrhea
- Fibroids
- None
- Other
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
Sexual History:
- Never had intercourse
- No intercourse since her LMP
- No intercourse in the last 3 months
- Other
When did your last normal menstrual begin?
________________________________
Physical Exam
Mood:
- Normal
- Anxious/worried
- Confused/inappropriate
- Lethargic
Patient’s color is:
- Normal
- Pale
- Flushed
- Jaundiced
- Cyanotic
Greatest tenderness is:
- Entire abdomen
- Upper abdomen
- RLQ
- LLQ
- Suprapubic
- Lower abdomen
- No tenderness
The abdomen is:
- Soft
- Voluntary guarding
- Involuntary guarding
- Mild rebound tenderness
- Moderate/marked rebound tenderness
On abdominal palpation:
- No masses
- Mass central lower abdomen
- Mass RLQ
- Mass LLQ
- Mass upper abdomen
Bowel sounds are:
- Normal
- Silent
- Hyperactive
- High-pitched, rushes
CVA pain/tenderness is:
- Present
- Absent
The vagina contains:
- Nothing abnormal
- Small amounts of blood
- Large amounts of blood
- Clots
- Pregnancy tissue
- Other
The hymen is:
- Intact
- Not intact
- Not visualized
The bladder is:
- Tender
- Non-tender
Cervix inspection:
- No abnormal findings
- Purple discoloration
- Purulent (muco) discharge
- Tissue protruding from the os
- Bleeding from the os
Cervical Palpation:
- No abnormal findings
- Cervix is softer than expected
- Tender to touch
- Mild pain on movement
- Moderate/severe pain on movement
- Dilated at least 1 cm.
- Other
The uterine size is:
- Normal
- Slightly enlarged
- Moderately enlarged
Uterine palpation:
- No abnormal findings
- Soft
- Irregular contour
- Mildly tender
- Mod/severe tenderness
Left adnexa:
- Normal
- Tender mass
- Non-tender mass
- Tenderness, no mass
Right adnexa:
- Normal
- Tender mass
- Non-tender mass
- Tenderness, no mass
Culdesac:
- Normal
- Tender mass
- Non-tender mass
- Tenderness, no mass
- Tender nodules on uterosacral ligaments