Pelvic Inflammatory Disease

HISTORY:

‍Lower abdominal painPelvic painVaginal discharge for ‍ ‍hoursdays

‍lower abdominal pain

‍pelvic pain

‍vaginal discharge, ‍clear, ‍thin

‍fishy smell

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍irregular menstrual bleeding

‍painful intercourse

‍painful urination

‍nausea

‍vomiting

‍changes in bowel movements

Last menstrual period: ‍ ‍daysweeksmonths ago

Worsening factors: ‍none

Treatments tried: ‍none, ‍effectiveineffective



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Anorectal: DRE ‍normal, anus ‍normal

Pelvic:

- External genitalia: ‍normal, ‍inguinal lymphadenopathy

- Vagina: ‍normal, discharge ‍normal, ‍malodorous

- Cervix: ‍normal

- Uterus: ‍normal, ‍no cervical motion tenderness

- Adnexa: -R ‍normal, -L ‍normal

- Tests performed: ‍Pap test, ‍HPV DNA, ‍vaginal culture, ‍chlamydia/gonorrhea, vaginal pH ‍< 4.5> 4.5, whiff test with KOH ‍negative

- Performed with chaperone



ASSESSMENT:

‍Pelvic inflammatory disease ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍CBC, ‍electrolytes, ‍creatinine, ‍CRP, ‍ESR

- Urinalysis

- Urine culture

- Pelvic ultrasound

- ‍Antibiotics

- ‍Analgesics

- Sexual partners treatment

- Abstinence until treatment completed and symptoms resolved

- Counseling on condom use

- Consider IUD removal in some cases

- Referral to gynecologist

- Referral to infectious disease specialist

- Follow-up in ‍ ‍daysweeks

- Return if symptoms worsen or if new symptoms develop such as fever, vomiting, or increased pain

- Go to ER if severe abdominal pain, severe vomiting, or fever occurs