Aim: Acute abdomen constitutes 5–10% of all emergency department visits and is the leading cause of hospital admissions. The clinical scenario of two patients with the same underlying pathology may look different or similar with the disease entities very distinct. Background: Diagnosis of acute abdomen requires meticulous history taking, a thorough evaluation of symptoms, evaluation, and prudent use of investigations to specify the disease and management which many times could be surgery. Accurate knowledge is essential for appropriate and timely decisions. The clinical presentation included pain in the abdomen (16.6%), pain in the abdomen and vomiting (44.4%), pain in the abdomen in shock (39%), and abdominal tenderness (33.3%). Discussion: Retrospective study conducted in a tertiary care center after ethical committee approval. The term acute abdomen refers to any serious acute intra-abdominal condition accompanied by pain, tenderness, and muscular rigidity, for which emergency surgery should be contemplated. It is often indicative of a clinical course of abdominal symptoms that can range from minutes to hours to weeks and is commonly used synonymously for a condition that requires immediate surgical intervention. Conclusion: Diagnosis of pelvic pain in women can be challenging because many symptoms and signs are insensitive and non-specific. As the first priority, urgent life-threatening conditions (e.g., ectopic pregnancy, appendicitis, and ruptured ovarian cyst) and fertility-threatening conditions (e.g., pelvic inflammatory disease, and ovarian torsion) must be considered. Clinical significance: A good clinical acumen along with diagnostic intervention aids in diagnosing acute abdomen aptly.