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Morning Report. Gaby Paskin 7/22/13. 17 year old female comes to your office with abdominal pain x 4 days. . Right lower quadrant Constant but worse with jarring movements No radiation LMP 2 week ago, but notice she was spotting this week Sexual active, new partner On OCP No fevers

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morning report

Morning Report

Gaby Paskin

7/22/13

17 year old female comes to your office with abdominal pain x 4 days
17 year old female comes to your office with abdominal pain x 4 days.
  • Right lower quadrant
  • Constant but worse with jarring movements
  • No radiation
  • LMP 2 week ago, but notice she was spotting this week
  • Sexual active, new partner
  • On OCP
  • No fevers
  • Had more discharge than usual
slide3
DDx
  • Ectopic Pregnancy
  • Appendicitis
  • Ovarian Torsion
  • Dysmenorrhea
  • Mittelschmerz
  • Rupture ovarian cyst
  • Nephrolithiasis
  • UTI
  • Spontaneous abortion
  • Endometriosis
  • Ovarian tumor
  • Sexual assault
  • Cholecystitis
  • Constipation
  • AGE
  • IBD
physical exam
Physical Exam
  • T98, HR 9,0 RR 16, BP 110/65
  • Well appearing
  • Lower quadrant pain on R
  • No rebound tenderness
  • Pelvic exam:
    • Yellow vaginal discharge
    • CMT and R sides adnexal tenderness on exam
management
Management
  • What is her diagnosis?
  • Do you want to order labs?
  • Do you think she needs imaging?
  • How do you want to treat her?
  • Inpatient or outpatient?
  • Does she need to come back to the office?
pelvic inflammatory disease
Pelvic Inflammatory Disease
  • Acute infection of the upper genital tract structures
    • Uterus, fallopian tubes, ovaries
    • Leads to endometritis, salpingitis, oophoritis, peritonitis
  • Neisseria gonorrheae, Chlamydia trachomatis, and vaginal flora
pathogenesis
Pathogenesis
  • Disruption of normal vaginal flora
  • Disturbance of cervical barrier
  • Micro:
    • Neisseria gonorrhoeae
      • 15% of women with endocervical gonorrhea develop PID
      • 1/3 of PID cases
    • Chlamydia trachomatis
      • 15% of endocervical Chlamydia produce PID
    • Unknown other agents
    • Polymicrobal infection
clinical features
Clinical Features
  • Abdominal pain
    • Worse during sex and jarring movements, pain during or shortly after menses
    • Usually bilateral
  • Abnormal uterine bleeding
  • New vaginal discharge
  • Urethritis
risk factors
Risk factors
  • Age < 25 (highest risk age 15-25)
  • Young age at first sex
  • Non barrier contraception
  • New, multiple or symptomatic sexual partners
  • Oral contraceptives
  • Previous episode of PID
  • Sex during menses
  • Vaginal douching
  • Bacterial vaginosis
  • Intrauterine device (1st 3 weeks)
on exam
On exam
  • Fever
  • Diffuse abdominal tenderness greatest in lower quadrants
  • Can have rebound tenderness
  • Purulent endocervical discharge
  • Cervical motion, uterine or adnexal tenderness
  • Palpable adnexal mass
  • RUQ pain-Fitz-Hugh Curtis syndrome
fitz hugh curtis syndrome
Fitz-Hugh Curtis Syndrome
  • Perihepatitis
  • Patchy purulent and fibrinous exudate
  • RUQ pain
  • Pleuritic component
  • Can be referred to right shoulder
diagnostic criteria
Diagnostic Criteria
  • PID is a clinical diagnosis
  • Low threshold for diagnosis!
  • Clinical Criteria:
    • Lower abdominal pain
    • Cervical motion tenderness, uterine tenderness or adnexal tenderness
  • Supporting Criteria
    • Oral temperature >101° (38.3°)
    • Abnormal cervical or vaginal mucopurulent discharge
    • Presence of abundant numbers of WBC in vaginal secretions
    • Elevated ESR or CRP
confirmed pid
“Confirmed PID”
  • Pelvic pain and tenderness PLUS
    • Endometritis or acute salpingitis on histologic evaluation from a biopsy
    • N. gonorrheae or C. trachomatis in genital tract
    • Gross salpingitis visualized on laparoscopy or laparotomy
    • Isolation of pathogenic bacteria from a clean specimen from the upper genital tract
    • Inflammatory/purulent pelvic peritoneal fluid without another source
  • CDC “definitive PID”
    • One or more of the following
      • Histologic evidence of endometritis on biopsy
      • Imaging technique revealing thickened fluid-filled tubes with or without pelvic fluid or tuboovarian abscess
      • Laproscopic abnormalities consistent with PID
testing
Testing
  • Pregnancy test
  • CBC
  • Gram stain
  • Nucleic avid amplification test of Chlamydia and gonorrhea
  • UA
  • ESR/CRP
  • HIV testing
  • RPR
  • HepB surface Ag and Ab
  • Ultrasound
indication for hospitalization
Indication for hospitalization
  • Pregnancy
  • Lack of response or tolerance to oral medications
  • Nonadherence to therapy
  • Inability to take oral medications due to nausea and vomiting
  • Severe clinical illness (high fever, nausea, vomiting, severe abdominal pain)
  • Complicated PID with pelvic abscess
  • Possible need for surgical intervention or diagnostic exploration for alternative etiology
treatment
Treatment
  • Requires broad spectrum coverage
  • Outpatient
    • Ceftriaxone IM x1 plus doxycycline x 14 days
    • Cefoxitin IM x 1 with probenecid x1 plus doxy x 14 days
    • +/- metronidazole
  • Follow up 48-72 hours to follow improvement
    • If no improvement in 72 hours, should be hospitalized
treatment continued
Treatment continued
  • Inpatient
    • Cefoxitin plus doxycycline
    • Clindamycin plus gentamicin loading does followed by maintenance
    • Change to PO after 24 hours of sustained clinical improvement
      • 14 day course of doxycycline, if abscess clindamycin or metronidazole with doxy
  • Anaerobic coverage: metronidazole
    • Severe infection, tubo-ovarian abscess
long term complications
Long term complications
  • Recurrent PID
  • Hydrosalpinx
  • Chronic pelvic pain
  • Infertility
  • Ectopic pregnancy
question 1
Question 1
  • You are seeing a 15 year old sexually active girl who complains of vague lower abdominal pain and vaginal discharge. She has no systemic symptoms but has experienced intermittent dysuria over the last week. She believes that she needs only a prescription for a yeast infection because was treated for this a few weeks ago but the discharge did not resolve completely.
  • Of the following, the MOST appropriate next step is
  • A. Obtain a vaginal swab for a wet mount evaluation only
  • B. Perform a speculum and bimanual examination
  • C. Perform an external genital inspection only
  • D. Provide an antifungal prescription
  • E. Send a urine specimen for culture only
question 2
Question 2
  • A 16 year old girl comes to your office with complaints of a thick white vaginal discharge. She is sexually active with one partner with whom she always uses condoms. She has no complaints of fever or abdominal pain, but she reports external “burning” if the vaginal area when she urinates. Pelvic exam reveals fiery red labia majora and minora and an adherent white discharge on the vaginal walls with a moderate amount of white discharge in the vaginal vault. The speculum exam is uncomfortable for her, but there is not cervical motion, uterine or adnexal tenderness, and the cervix shows no friability or discharge.
slide22

Of the following, the MOST likely pathogen responsible for this patient’s symptoms is

  • A. Candida albicans
  • B. Chlamydia trachomatis
  • C. Group A Streptococcus
  • D. Neisseriagonorrhoeae
  • E. Trichomonasvaginalis
question 3
Question 3
  • A 16 year old sexually active girl presents with lower abdominal pain for 2 days duration. She finished her last menstrual period a few days ago and notes that it was heavier and more painful than usual. On PE, she is afebrile, has normal vital signs, and exhibits diffuse lower abdominal tenderness with no rebound or guarding. Bimanual examination elicits pain on movement of her cervix and palpation of her adnexa, with no palpable masses.
  • Of the following, the MOST appropriate next step is to obtain a
  • A. CBC and ESR
  • B. Gram stain of any cervical discharge
  • C. Pelvic ultrasound
  • D. Test for nucleic acid amplification test for gonorrhea and Chlamydia
  • E. Urine and blood culture