| Patient's name URN
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ACUTE ABDOMINAL PAIN
| Age | Sex | ||||||
| Ethnicity | |||||||
| HISTORY | |||||||
| ABDOMINAL PAIN (Circle as many as you need) | |||||||
| Onset | Sudden | Rapid | Gradual | __________ | hrs/days | ||
| (secs) | (min) | (hrs/days) | (Give details) | ||||
| Character | Sharp | Dull | Pattern |
Constant |
Colicky |
||
| Location | Diffuse | RUQ | Epigastric | LUQ | |||
| Poorly localised | Right flank | Central | Left flank | ||||
| Shifting | Right loin | Back | Left loin | ||||
| Left iliac fossa | Pelvic Suprapubic |
Right iliac fossa | |||||
| Chronology | Unremitting | Intermittent | |||||
| Worsening | Improving | Unchanging | Fluctuating | ||||
| Alleviating factors | Analgesia/Dose/Frequency ____________________ | Other __________________________ | |||||
| (Give details) | (Give details) |
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| Aggravating factors | Food _________________ | Posture____________ | Movement ________________ | ||||
(Give details) |
(Give details) |
(Give details) |
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| Upper GI symptoms | Waterbrash | Heartburn | Vomiting | Haematemesis _____ (No. of episodes) | |||
| Lower GI symptoms | Diarrhoea | Malaena | PR blood loss ____ (No. of episodes) |
Pale stools | |||
Constipation |
Last bowel movement _______ (days) | Usual frequency _____ per _____ | |||||
| Urinary symptoms | Dysuria | Frequency | Haematuria | Dark urine | |||
| Gynaecologic symptoms | PV discharge | Dyspareunia | |||||
| Additional comments: | ____________________________________________________________________________ | ||||||
| Past abdominal surgery | _____________________________________________________________ (Give details) | ||||||
| Menstrual history | LMP ____/____ | Cycle ____/____ | |||||
| Gynaecological history | STDs | IUCD | |||||
| Obstetric history | G_____ | P_____ | Previous ectopic | Peri-partum complications | _____ (Give details) | ||
| Miscellaneous | Travel history __________________________ | Contaminated Food water exposure _________________ |
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| Past medical history | Medications |
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| Smokes | ________ | ||||||
| Alcohol | ________ | ||||||
| Fasted from: | ____:____ | ||||||
EXAMINATION |
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Vital Signs |
Temp_____ | PR _____ | BP ______ | SaO2 _____% | RR_______ | ||
| Fever | Dehydration | Tachycardia | Halitosis | ||||
| Jaundice | Anaemia | ||||||
| Abdominal exam | (Please circle) |
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| (Draw diagram) | Cough tenderness |
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| Percussion
tenderness |
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| Rebound tenderness |
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| Voluntary guarding |
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| Involuntary
guarding |
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| Bowel sounds |
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| Rectal examination | Masses | Tenderness | Blood | Malaena | Haemoccult | ||
| Urinalysis | Blood | Nitrate | Leucocytes | pH | |||
| Glucose | Ketones | Biliribin | Urobilinogen | ||||
| bHCG | Positive | Negative | |||||
| DIFFERENTIAL DIAGNOSES | MANAGEMENT PLAN | ||||||