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Albert L. Song MD-MBA140125 25 January 2017 - Gynecology

I. Identifying Information
P.D. is a 30 year old female, single, nulligravid, call-center agent who is not yet assessed.

II. Chief Complaint

P.D. comes in with a chief complaint of hypogastric pain.

III. History of Present Illness

2 weeks PTC, the patient reported to have unprotected sex. 1 week PTC, the patient reported to
have unprotected sex again with the same partner but experienced dyspareunia. 6 days PTC, the
patient experienced dull hypogastric pain radiating to the right hypogastric area with accompanying
yellowish non-foul smelling vaginal discharge. The symptoms persisted up to the day of consultation.
The patient denies fever, nausea, vomiting, dysuria, flank pains, hematuria, and frequency or any
change in bowel movements.

IV. Review of Systems

General Genitourinary
(-) Fever (-) dysuria
(-) flank pain
Gastrointestinal (-) hematuria
(-) nausea (+) dyspareunia
(-) vomiting (+) discharge (yellow, non-foul)
(-) change in bowel habits

V. Past Medical History

Unremarkable

VI. Family History

The patients mother is positive for diabetes mellitus with an unrecalled type. The patients father
is positive for hypertension with an unrecalled stage.

VII. Reproductive History

The patients LMP was on Dec 30, 2016 while her PMP was on Nov 29, 2016. Her menstruations
are reported to be regular with a duration of 3 days. The patient denies the use of any form of
contraceptives. The patients first sexual contact was 5 years ago and the most recent partner is her
3rd partner.
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VIII. Stakeholder Analysis

Family Stake/WIIFM Stand on Intensity Degree Insight/Action

Member the Issue of Stand of
Influenc
e
Patient Experiences anxiety Ally High High The patient seeks relief from
over her health anxiety over her heavy
condition, primary menstrual bleeding.
decision maker on Management interventions
health matters, finances may force absences from
all health decisions and work incurring loss in
expenses, employed as a income.
call center agent

Sexual partner Possible emotional Unknown Low Low Possible sexually

attachment to patient transmitted infections may
have been acquired.

IX. Physical Examination

General Speculum Examination

Patient was alert and awake. Mucopurulent, non-foul smelling, mucoid
Vital Signs discharge at cervical os
Stable BP Cervix is slightly erythematous
Stable RR (-) Cervical polyps
Stable HR Internal Examination
Stable Temp (+) Tender cervix
General Survey (-) Adnexal masses
Unremarkable (+) Right adnexal tenderness
Abdomen
Inspection
o Unremarkable
Auscultation
o Unremarkable
Percussion
o Unremarkable
Palpation
o Direct tenderness over hypogastric area
(7/10)
o Direct tenderness over right lower
quadrant (7/10)
o Slight rebound tenderness
o (-) CVA tenderness
o (-) Rovsings
o (-) Obturator
o (-) Psoas

X. Primary Impression
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The patient is suspected to have Pelvic Inflammatory Disease with the basis of: multiple sexual
partners (3), (+) mucopurulent, yellowish, mucoid vaginal discharge, (+) right adnexal tenderness, (+)
cervical motion tenderness, and her chief complaint, (+) hypogastric pain.

XI. Differential Diagnosis

1. Appendicitis
a. Rule In:
i. (+) Right lower quadrant tenderness
ii. (+) Rebound tenderness
b. Rule Out:
i. (-) Rovsings Sign
ii. (-) Obturator Sign
iii. (-) Psoas Sign
iv. (-) Rales
c. Diagnostics:
i. WBC Count

Kasper, D. L., Hauser, S. L., Jameson, L., Fauci, A. S., Longo, D. L., & Loscalzo, J. (2015).
Harrison's Principle of Internal Medicine (19th Edition ed.). New York: McGrawHill.

2. Corpus Luteum Cyst

a. Rule In:
i. (+) Right adnexal tenderness
ii. (+) Direct tenderness over hypogastric area
iii. (+) RLQ rebound tenderness
iv. (+) Unilateral mid-cycle acute pain
v. (+) Dyspareunia
b. Rule Out:
i. (-) Spotting
ii. (?) Delay in normal period
iii. (-) Adnexal mass
c. Diagnostics:
i. Ultrasound and CT Scan

Lobo, R. A., In Gershenson, D. M., In Lentz, G. M., & In Valea, F. A. (2017). Comprehensive
gynecology.

3. Torsion of Adnexal Mass

a. Rule In:
i. (+) Hypogastric pain
ii. (+) Dyspnea
b. Rule Out:
i. (-) Vomiting
c. Diagnostics:
i. TransVaginal Ultrasonogram
ii. Doppler Ultrasound

Lobo, R. A., In Gershenson, D. M., In Lentz, G. M., & In Valea, F. A. (2017). Comprehensive
gynecology.

XII. Diagnostic Criteria

Minimum Criteria (at least one):

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- Cervical motion tenderness

- Uterine tenderness
- Adnexal tenderness
Additional Criteria (at least one):
- Oral temperature >38.3 deg C
- Abnormal cervical mucopurulent discharge or cervical friability
- Presence of abundance numbers of WBC on saline microscopy of vaginal fluid
- Elevated ESR
- Elevated CRP
- Lab documentation of infection with Neisseria gonorrhoeae or Chlamydia trachomatis

XIII. Management
Out-patient treatment
- Ceftriaxone 250 mg IM single dose
- Doxycycline 100 mg PO twice a day for 14 days
- Metronidazole 500 mg PO twice a day for 14 days

Indications for Admission

- Surgical emergency (e.g. Appendicitis)
- Pregnancy
- Unable to follow or not tolerated OPD treatment
- Severe illness
- Tubo-ovarian abscess

Parenteral Regimen
- Clindamycin 900 mg IV every 8 hours
- Gentamicin loading dose IV or 2mg/kg IM
- Gentamicin maintenance dose 0.2 mg/kg every 8 hours

XIV. Sequelae

One possible sequelae of this is perihepatitis or Fitz-Hugh-Curtis syndrome where there is already
peritoneal involvement caused by the PID etiologic agents such as N. gonorrhoeae or C. trachomatis.
This causes localized fibrosis or scarring of peritoneal structures.

XV. Prevention

Follow up after 3-6 months after treatment for re-testing for N. gonorrhoeae or C. trachomatis
infection. HIV testing should also be offered. Her sexual partners should also be tested for the
etiologic agents as well as for the HIV. The partner should be given the same treatment even if
asymptomatic.

XVI. References

Dra. Maricel Tys lecture on Acute Pelvic Pain.