What is the initial management for a female patient presenting with nausea, vomiting, suprapubic and left iliac fossa pain and tenderness, with a negative pregnancy test, normal urine dipstick results, and normal White Blood Cell (WBC) counts?

From the Guidelines

The initial management for this female patient with nausea, vomiting, and lower abdominal pain should be analgesia and discharge (option D). Since the patient has normal white blood cell counts, a negative pregnancy test, and normal urine dipstick, there are no immediate concerning findings that would necessitate invasive procedures or advanced imaging. According to the World Journal of Emergency Surgery study 1, a step-up approach for diagnosis should be used, beginning with clinical and laboratory examination and progressing to imaging examinations, which supports starting with a conservative approach.

The patient's presentation of nausea, vomiting, and abdominal pain could be indicative of several conditions, and a thorough clinical evaluation is essential to guide further management. As stated in the study 1, physical evaluation may limit the differential diagnosis to direct decisions regarding a proper management plan, including the need for appropriate diagnostic testing and whether emergent intervention is required.

Given the absence of signs of systemic inflammation, sepsis, or acute organ failure, and considering the patient's stable condition, analgesia and discharge with follow-up instructions is the most appropriate initial management. This approach prioritizes the patient's quality of life, minimizes potential morbidity associated with unnecessary procedures, and avoids mortality risks associated with delayed diagnosis of more severe conditions.

Key points to consider in the initial management include:

• Normal white blood cell counts and negative pregnancy test reduce the likelihood of certain acute conditions
• Normal urine dipstick results decrease the suspicion for urinary tract infections
• The absence of systemic signs of infection or sepsis allows for a more conservative initial approach
• A step-up approach to diagnosis, as recommended by the study 1, supports starting with clinical evaluation and symptom management before progressing to more invasive diagnostic procedures or imaging.

Diagnostic laparoscopy, while gaining acceptance in emergency surgery for identifying and treating the causative pathology of acute abdominal pain 1, is typically reserved for cases where conservative management has failed or when there are more concerning clinical features. Thus, it is not the initial management step for this patient.

From the Research

Initial Management of Acute Abdominal Pain

The initial management of a female patient presenting with nausea, vomiting, suprapubic and left iliac fossa pain, and tenderness, with a negative pregnancy test, normal urine dipstick, and normal WBC counts, is crucial for accurate diagnosis and treatment.

• The patient's symptoms suggest acute abdominal pain, which can be caused by various conditions, including appendicitis, ovarian cysts, and other intra-abdominal diseases.
• Diagnostic laparoscopy is a minimally invasive surgical procedure that can be used to diagnose and treat intra-abdominal diseases, as discussed in 2.
• The use of diagnostic laparoscopy in emergency settings, especially in underserved areas, can be beneficial in optimizing diagnosis and management of acute abdominal conditions, as reported in 3.
• A review of the epidemiology, diagnosis, and general principles of surgical management in patients with acute abdomen suggests that diagnostic laparoscopy should be considered in patients without a specific diagnosis after appropriate imaging, as stated in 4.
• The selective use of diagnostic laparoscopy in patients with suspected appendicitis can reduce the negative appendectomy rate and provide other diagnoses, mostly gynecologic in nature, as found in 5.
• A comparison of the diagnostic value of laparoscopy, abdominal computed tomography, and ultrasonography in acute appendicitis shows that laparoscopy achieves early and accurate diagnosis and can reduce the incidence of perforated appendicitis, as concluded in 6.

Choice of Diagnostic Laparoscopy

The choice of diagnostic laparoscopy as the initial management option is based on its ability to provide an accurate diagnosis and treatment of intra-abdominal diseases, as well as its minimally invasive nature.

• The patient's symptoms and negative diagnostic tests suggest that a more invasive diagnostic procedure, such as diagnostic laparoscopy, may be necessary to determine the cause of her symptoms.
• The use of diagnostic laparoscopy in this case can help to avoid unnecessary exposure to radiation and provide a definitive diagnosis and treatment plan, as discussed in 2, 3, 4, 5, 6.