patient care and procedure case study

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Diagnosis:

The complete diagnosis for this patient is pelvic inflammatory disease, gonorrhea, perihepatitis, anemia and bacterial vaginosis.

Pelvic Inflammatory Disease (PID) is a syndrome created by the ascent of microorganisms from the vagina and endocervix to the endometrium, fallopian tubes, ovaries, and associated structures. This very broad diagnosis can include all varieties of upper genital tract infections, which are unrelated to pregnancy or surgical intervention. The included diagnosis encompass salpingitis, salpingo-oophoritis, endometritis, tubo-ovarian inflammatory masses and pelvic or diffuse peritonitis.

The precise mechanism by which organisms ascend the lower genital tract is unknown but there is some speculation. Perhaps chlamydial or gonoccocal endocervicitis alter the defense mechanisms of the cervix. Factors, which predispose patients to PID, include the use of an intrauterine device (IUD) and the hormonal and physical changes associated with menstruation.

Common signs and symptoms include lower abdominal pain, fever, malaise, vaginal discharge, irregular bleeding, cervical motion testing, nausea, and vomiting.

PATIENT RESULTS: The patient’s escutcheon is of the female pattern; there are no rashes or excoriations on the external genitalia; the labia are symmetric; the urethral orifice is open and without discharge, situated just below the clitoris; the introitus is without inflammation or visible lesions; no cystocele or rectocele is noted when the patient strains. On speculum exam, the vagina easily admits the speculum; the vaginal walls are pink, moist and elastic, with prominent rugae; there is blood in the vaginal vault. The cervix is symmetric and open; it appears inflamed and there is a small amount of mucopus at the cervical os.

The description of this woman’s pain localizes the problem to the lower abdomen, necessitating a pelvic exam. The presence of cervical discharge indicates cervicitis. In combination with the lower abdominal pain, this finding should raise suspicion for pelvic inflammatory disease (PID).

This patient has the classic signs and symptoms of pelvic inflammatory disease: low abdominal pain, bilateral adnexal tenderness, and cervical motion tenderness. PID should be high on the differential diagnosis of any sexually active woman with these findings. Additional findings such as the presence of cervical mucopus and a positive test for N. gonorrhoeae make the diagnosis of PID even more likely. A woman with these findings my be treated empirically for PID if she does not appear acutely ill and if pregnancy has been ruled out. However, many experts recommend that a woman of this young age be admitted to the hospital for definitive diagnosis and treatment.

Abdominal or pelvic pain in a sexually active woman can be due to a wide variety of causes. Acute appendicitis should be considered but more often presents with unilateral pain in the right lower quadrant. Ectopic pregnancy is a serious consideration in a woman with low abdominal pain. Menstrual history, sexual history, a pregnancy test, and ultrasound are necessary to assess this possibility. Renal or ureteral stones should also be considered in the differential diagnosis and a urinalysis looking for blood should be performed.

Additional diagnoses such as fitz-hugh-curtis syndrome (perihepatitis), iron deficiency anemia, and bacterial vaginosis are made in the course of a thorough work-up of this patient.

Obtaining a past medical history and history of medications are important parts of the evaluation of a seriously ill patient. Questions about alcohol and drug use are appropriate. Given the nature of her problem, key questions from the gastrointestinal and genitourinary review of systems should also be asked. Vital signs and a thorough abdominal exam are appropriate. Given the presence of a cervical discharge, a gram stain and testing for Chlamydia trachomatis are indicated in addition to testing for gonorrhea. Her anemia warrants additional evaluation with a peripheral smear, serum iron and iron binding capacity. Given the results of her ultrasound, a laparoscopy is indicated to confirm the diagnosis and begin treatment. Once the diagnosis of PID has been established, the patient should be tested for other sexually transmitted diseases such as syphilis and HIV.

In a patient with both abdominal and pelvic pain, the differential diagnosis includes appendicitis, ectopic pregnancy, PID, endometriosis, and a pelvic abscess. Consultation with a gynecologist is critical because laparoscopy may be necessary. If the diagnosis of PID is confirmed or strongly suspected, treatment with antimicrobial agents is necessary. Many different antibiotic regimens are appropriate and the recommendations of the Centers for Disease Control should be followed. Effective treatment should include a combination of antibiotics effective against C. trachomatis, N. gonorrhoeae, vaginal anaerobes, and enteric gram negative rods. Intravenous fluids should be administered because this patient is severely ill, has fever, and may need to be kept NPO for the possibility of abdominal surgery. Counseling and education about sexually transmitted diseases, contraception and barrier protection is required for any patient with a sexually transmitted disease. A follow-up visit to monitor the abdominal and genital exam findings is necessary to assess the response to therapy.

Bed rest is recommended in this patient to assist in pain control and prevent the worsening of symptoms. Any patient in whom surgery or laparoscopy may be required for diagnosis or treatment should be kept NPO until this question is resolved. Narcotic analgesics are recommended for pain control once the diagnosis has been established. Abstinence is the recommended form of contraception for adolescents. However, oral or intramuscular contraceptives can be prescribed in addition to barrier methods if requested by the patient.

Abdominal and bimanual examinations should be done in follow-up to assess this patient’s response to therapy.

In a patient with severe pelvic inflammatory disease and tubal abscess, a follow-up ultrasound may be indicated to ensure the disease process has completely resolved.

 
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