30F - Diffuse Abdominal Pain x 8 Days: Full Clinical Management Plan

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STEP 1: MUST NOT MISS (Rule Out First)

Pregnancy test (urine/serum beta-hCG) is MANDATORY before any other workup. An ectopic pregnancy can masquerade as a threatened miscarriage in early stages and must always be considered in the differential - ROSEN's Emergency Medicine

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STEP 2: HISTORY (Focused)

Pain Characterization

• Onset - sudden vs gradual?
• Character - colicky, constant, burning, cramping?
• Radiation - to shoulder, back, groin?
• Progression - improving or worsening?
• What makes it better/worse - food, movement, position?

Gynecological History (CRITICAL in a 30F)

• Last menstrual period (LMP) - any missed/late periods?
• Sexual activity + contraception use
• Prior STIs, PID episodes, or ectopic pregnancy
• Vaginal discharge or abnormal bleeding?
• Dyspareunia (pain with intercourse)?

GI History

• Nausea, vomiting, diarrhea, constipation?
• Blood or mucus in stool?
• Relationship to meals?

Systemic

• Fever, chills, rigors?
• Weight loss?
• Urinary symptoms (UTI, renal colic)?
• Travel history (infectious causes)?

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STEP 3: PHYSICAL EXAMINATION

General

• Vital signs: fever (>38°C), tachycardia, hypotension = red flag for sepsis/hemorrhage
• Appearance: distress, pallor, jaundice

Abdominal Exam

Pelvic Examination (mandatory in reproductive-age female)

• Cervical motion tenderness (CMT) - pathognomonic for PID
• Adnexal tenderness/mass - ovarian cyst, torsion, ectopic, TOA
• Mucopurulent cervical discharge - suggests PID/STI
• Uterine tenderness - endometritis

Minimum CDC criteria for presumptive PID diagnosis: any ONE of cervical motion tenderness, uterine tenderness, or adnexal tenderness - in a sexually active woman at risk for STIs with no other diagnosis identified. - ROSEN's Emergency Medicine

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STEP 4: DIFFERENTIAL DIAGNOSIS (30F, Diffuse Pain, 8 Days)

Gynecological (highest priority in this demographic)

Gastrointestinal

Urological

Other / Systemic

• Diabetic ketoacidosis
• Acute intermittent porphyria
• Familial Mediterranean fever
• Functional/psychosomatic pain

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STEP 5: INVESTIGATIONS

First-Line (All Patients - Order Simultaneously)

Imaging

Microbiology (if STI/PID suspected)

• High vaginal swab + endocervical swab for Gonorrhoea + Chlamydia (NAAT)
• Cervical discharge microscopy

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STEP 6: MANAGEMENT

If Ectopic Pregnancy Suspected (hCG +ve, no IUP on USS)

• Immediate surgical/gynae referral
• IV access, crossmatch blood
• Monitor vitals closely
• Options: expectant, medical (methotrexate), or surgical (salpingostomy/salpingectomy)

If PID Diagnosed or Strongly Suspected

• Surgical emergency cannot be excluded (e.g. appendicitis)
• Tubo-ovarian abscess present
• Pregnancy
• Severe illness, high fever, persistent vomiting
• Failed outpatient therapy within 72 hours

• Ceftriaxone 500 mg IM single dose +
• Doxycycline 100 mg PO BD x 14 days +
• Metronidazole 400 mg PO BD x 14 days
• Advise: abstain from sex until patient and partner complete treatment
• Follow-up within 72 hours to assess response

• Cefoxitin/cefotetan IV + Doxycycline IV/PO
• Transition to oral after clinical improvement, complete 14-day course

Total duration of antibiotic therapy for PID is 14 days - ROSEN's Emergency Medicine

If Ovarian Torsion Suspected

• Urgent gynae referral - surgical emergency
• Laparoscopic detorsion ideally within hours to preserve ovarian function
• Doppler USS to assess flow (absent flow = late torsion)

If Appendicitis Suspected

• Surgical consult
• CT/USS confirmation
• Appendicectomy (laparoscopic or open)

If TOA (Tubo-Ovarian Abscess)

• Admit, IV antibiotics
• Drain if no response in 72 hours (interventional radiology or surgical)

Supportive Care (all patients)

• IV fluids if dehydrated / septic
• Analgesia (paracetamol +/- NSAID, opioids if severe)
• Anti-emetics
• NBM if surgical emergency pending

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STEP 7: RED FLAGS - IMMEDIATE ACTION NEEDED

• Positive pregnancy test + pain (ectopic until proven otherwise)
• Hemodynamic instability (BP <90 systolic, HR >100)
• Signs of peritonitis (rigid abdomen, rebound, guarding)
• High fever + rigors + pelvic mass (TOA / sepsis)
• Absent bowel sounds + distension (obstruction / ileus)

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Summary Algorithm

30F + Diffuse Abdominal Pain x 8 days
          ↓
  → Pregnancy test (STAT)
  → Vitals + Pelvic exam
  → FBC, CRP, LFTs, amylase, U&E
  → USS pelvis (transvaginal preferred)
          ↓
hCG + ve → Ectopic workup → Gynae referral
          ↓
hCG - ve → USS findings:
  - Adnexal mass + no flow → Torsion → Surgery
  - Free fluid + CMT → PID / TOA → Antibiotics ± admit
  - Normal USS → Consider GI (appendicitis, IBD, IBS)
                 → CT abdomen if needed

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Immediate Pain Management - 30F, Diffuse Abdominal Pain x 8 days

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IMPORTANT PRINCIPLE FIRST

Do NOT withhold analgesia while awaiting diagnosis. The outdated practice of withholding pain relief in the acute abdomen to "preserve signs" has been disproven. Adequate analgesia does NOT mask peritoneal signs or impair clinical diagnosis. Treat the pain promptly - it is humane and does not delay assessment.

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Step-by-Step Analgesic Approach

1. Assess Pain Severity (NRS / VAS 0-10)

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2. Analgesic Ladder

Mild Pain (NRS 1-3)

• Paracetamol (Acetaminophen) 500-1000 mg PO every 6-8 hours
• Maximum: 4 g/day
• Safe, first-line, no GI side effects

Moderate Pain (NRS 4-6)

• Paracetamol 1000 mg PO/IV every 6 hours +
• Ibuprofen 400 mg PO every 8 hours with food (if no contraindications)
  • Caution: avoid NSAIDs if suspected GI bleed, renal impairment, or pregnancy
• Antispasmodic if colicky in nature: Hyoscine butylbromide (Buscopan) 10-20 mg PO/IV/IM

Severe Pain (NRS 7-10) or Not Responding to Oral

• Morphine 2-4 mg IV slow push, titrate every 10-15 min to effect
  • OR Tramadol 50-100 mg IV/IM (weaker opioid, suitable if morphine not available)
• Paracetamol 1 g IV infusion over 15 min (concurrent)
• Avoid IM injections where possible - unpredictable absorption
• Avoid Meperidine (Pethidine) - risk of neurotoxicity (seizures) from normeperidine accumulation

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3. Add-On Medications (as needed)

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4. Special Considerations by Suspected Cause

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5. Monitoring After Analgesia

• Reassess pain score every 30-60 minutes
• Monitor: BP, RR, SpO2 (especially after opioids)
• Have naloxone available if IV morphine given (reversal if respiratory depression)
• Do NOT discharge on opioids unless:
  • Diagnosis confirmed
  • Pain is clearly improving
  • Follow-up arranged within 24-48 hours
  • Short course only (3-5 days max if opioids prescribed outpatient)

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Quick Reference Card

Mild pain   → Paracetamol 1g PO q6h ± Buscopan
Moderate    → Paracetamol IV + Ibuprofen PO + Buscopan
Severe      → Morphine 2-4 mg IV (titrate) + Paracetamol 1g IV + Ondansetron
Always      → IV fluids if dehydrated, treat the CAUSE concurrently
Never       → Pethidine | Withhold analgesia | Discharge without diagnosis

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Meftal-Spas

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Composition

DS (Double Strength) variant: Mefenamic Acid 500 mg + Dicyclomine 20 mg

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How It Works (Dual Mechanism)

• Blocks COX-1 and COX-2 enzymes
• Inhibits prostaglandin synthesis
• Reduces pain, inflammation, and fever

• Anticholinergic action - blocks muscarinic receptors
• Relaxes smooth muscle of GI tract, uterus, urinary tract
• Stops sudden muscle spasms and cramps

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Uses

• Dysmenorrhea (primary menstrual cramps) - most common use
• Abdominal cramps and spasms
• Colicky abdominal pain (GI, biliary, renal)
• IUCD-induced cramping and pain
• Irritable bowel syndrome (IBS) - crampy component
• Post-procedure uterine cramping

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Dosage

• Take with or after food (reduces GI upset)
• Do not exceed 3 tablets/day (standard strength)
• Typical course: 3-5 days (not for long-term use)

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Is It Appropriate for This Patient?

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Side Effects

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Key Precautions

• Always rule out ectopic pregnancy first (urine hCG) before prescribing in a woman of reproductive age
• Avoid in peptic ulcer disease
• Avoid in last trimester of pregnancy
• Caution in breastfeeding
• Do not give with other NSAIDs simultaneously (e.g. Ibuprofen)
• Avoid driving if dizziness occurs (dicyclomine effect)

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Bottom Line for This Patient

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Which Analgesic to Give — When & Why

The Core Framework: Match Drug to Situation

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1. BY PAIN SEVERITY (WHO Analgesic Ladder)

Mild (1-3)     →  Paracetamol / NSAID
Moderate (4-6) →  Paracetamol + NSAID / Weak opioid
Severe (7-10)  →  Strong opioid + Paracetamol (combination)

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2. BY PAIN TYPE — Practical Drug Selection

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3. QUICK DRUG REFERENCE TABLE

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4. CONDITION-BASED QUICK PICK

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5. SPECIAL POPULATIONS — Analgesic Restrictions

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6. THE GOLDEN RULE — Multimodal Analgesia

Never rely on one drug alone for moderate-severe pain. Combine paracetamol + NSAID + antispasmodic (if spasm) = better pain control with lower doses and fewer side effects of each drug individually.

Mild        →  Paracetamol alone
Moderate    →  Paracetamol + NSAID ± Antispasmodic
Severe      →  Paracetamol + NSAID + Opioid (titrate)
Neuropathic →  Add Pregabalin / Amitriptyline