https://lmscontent.embanet.com/RC/MSN/NU664B/Rubri…Diagnos
https://lmscontent.embanet.com/RC/MSN/NU664B/Rubri…Diagnosis:The complete diagnosis for this patient is pelvicinflammatory disease, gonorrhea, perihepatitis, anemia and bacterial vaginosis.Pelvic Inflammatory Disease (PID) is a syndromecreated by the ascent of microorganisms from the vagina and endocervix to theendometrium, fallopian tubes, ovaries, and associated structures. This verybroad diagnosis can include all varieties of upper genital tract infections,which are unrelated to pregnancy or surgical intervention. The includeddiagnosis encompass salpingitis, salpingo-oophoritis, endometritis,tubo-ovarian inflammatory masses and pelvic or diffuse peritonitis.The precise mechanism by which organisms ascend thelower genital tract is unknown but there is some speculation. Perhapschlamydial or gonoccocal endocervicitis alter the defense mechanisms of thecervix. Factors, which predispose patients to PID, include the use of anintrauterine device (IUD) and the hormonal and physical changes associated withmenstruation.Common signs and symptoms include lower abdominalpain, fever, malaise, vaginal discharge, irregular bleeding, cervical motiontesting, nausea, and vomiting.PATIENT RESULTS: The patient’s escutcheon is of thefemale 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 orvisible lesions; no cystocele or rectocele is noted when the patient strains.On speculum exam, the vagina easily admits the speculum; the vaginal walls arepink, moist and elastic, with prominent rugae; there is blood in the vaginalvault. The cervix is symmetric and open; it appears inflamed and there is asmall amount of mucopus at the cervical os.The description of this woman’s pain localizes theproblem to the lower abdomen, necessitating a pelvic exam. The presence ofcervical discharge indicates cervicitis. In combination with the lowerabdominal pain, this finding should raise suspicion for pelvic inflammatorydisease (PID).This patient has the classic signs and symptoms ofpelvic inflammatory disease: low abdominal pain, bilateral adnexal tenderness,and cervical motion tenderness. PID should be high on the differentialdiagnosis of any sexually active woman with these findings. Additional findingssuch as the presence of cervical mucopus and a positive test for N. gonorrhoeaemake the diagnosis of PID even more likely. A woman with these findings my betreated empirically for PID if she does not appear acutely ill and if pregnancyhas been ruled out. However, many experts recommend that a woman of this youngage be admitted to the hospital for definitive diagnosis and treatment.Abdominal or pelvic pain in a sexually active womancan be due to a wide variety of causes. Acute appendicitis should be consideredbut more often presents with unilateral pain in the right lower quadrant. Ectopicpregnancy is a serious consideration in a woman with low abdominal pain.Menstrual history, sexual history, a pregnancy test, and ultrasound arenecessary to assess this possibility. Renal or ureteral stones should also beconsidered in the differential diagnosis and a urinalysis looking for bloodshould be performed.Additional diagnoses such as fitz-hugh-curtis syndrome(perihepatitis), iron deficiency anemia, and bacterial vaginosis are made inthe course of a thorough work-up of this patient. Obtaining a past medical history and history ofmedications are important parts of the evaluation of a seriously ill patient.Questions about alcohol and drug use are appropriate. Given the nature of herproblem, key questions from the gastrointestinal and genitourinary review ofsystems should also be asked. Vital signs and a thorough abdominal exam areappropriate. Given the presence of a cervical discharge, a gram stain andtesting for Chlamydia trachomatis are indicated in addition to testing forgonorrhea. Her anemia warrants additional evaluation with a peripheral smear,serum iron and iron binding capacity. Given the results of her ultrasound, alaparoscopy is indicated to confirm the diagnosis and begin treatment. Once thediagnosis of PID has been established, the patient should be tested for othersexually transmitted diseases such as syphilis and HIV.In a patient with both abdominal and pelvic pain, thedifferential diagnosis includes appendicitis, ectopic pregnancy, PID,endometriosis, and a pelvic abscess. Consultation with a gynecologist iscritical because laparoscopy may be necessary. If the diagnosis of PID isconfirmed or strongly suspected, treatment with antimicrobial agents isnecessary. Many different antibiotic regimens are appropriate and therecommendations of the Centers for Disease Control should be followed.Effective treatment should include a combination of antibiotics effectiveagainst C. trachomatis, N. gonorrhoeae, vaginal anaerobes, and enteric gramnegative rods. Intravenous fluids should be administered because this patientis severely ill, has fever, and may need to be kept NPO for the possibility ofabdominal surgery. Counseling and education about sexually transmitteddiseases, contraception and barrier protection is required for any patient witha sexually transmitted disease. A follow-up visit to monitor the abdominal andgenital exam findings is necessary to assess the response to therapy.Bed rest is recommended in this patient to assist inpain control and prevent the worsening of symptoms. Any patient in whom surgeryor laparoscopy may be required for diagnosis or treatment should be kept NPOuntil this question is resolved. Narcotic analgesics are recommended for paincontrol once the diagnosis has been established. Abstinence is the recommendedform of contraception for adolescents. However, oral or intramuscularcontraceptives can be prescribed in addition to barrier methods if requested bythe patient.Abdominal and bimanual examinations should be done infollow-up to assess this patient’s response to therapy.In a patient with severe pelvic inflammatory diseaseand tubal abscess, a follow-up ultrasound may be indicated to ensure thedisease process has completely resolved.
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