Pelvic Inflammatory Disease

‍‍HISTORY: 
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‍‍Last menstrual period: ‍﻿ ‍﻿ ago
‍‍Worsening factors: ‍﻿﻿
‍‍Treatments tried: ‍﻿, ‍﻿﻿
‍‍‍‍Other elements:
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‍‍EXAM: 
‍‍General appearance: ﻿
‍‍Vital signs: ‍﻿, BP ‍﻿, HR ‍﻿, RR ‍﻿, SpO2 ‍﻿ %, Temp ‍﻿°
‍‍Neck: ﻿
‍‍Heart: , ﻿
‍‍Lungs: , ‍﻿﻿
‍‍Abdomen: ,  ‍﻿, , ‍﻿﻿
‍‍Anorectal: DRE ‍﻿, anus ‍﻿﻿
‍‍Pelvic: 
‍‍- External genitalia: , ‍﻿﻿
‍‍- Vagina: , discharge ‍﻿, ‍﻿﻿
‍‍- Cervix: ﻿
‍‍- Uterus: , ﻿
‍‍- Adnexa: -R , -L ﻿
‍‍- Tests performed: ‍﻿, ‍﻿, ‍﻿, ‍﻿, vaginal pH ‍﻿, whiff test with KOH ‍﻿﻿
‍‍- Performed with chaperone
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‍‍ASSESSMENT: 
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‍‍DDx: ‍﻿﻿
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‍‍PLAN: 
‍‍- Blood work: ‍﻿, ‍﻿, ‍﻿, ‍﻿, ‍﻿﻿
‍‍- Urinalysis
‍‍- Urine culture
‍‍- Pelvic ultrasound
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‍‍- 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 ‍﻿ ‍﻿﻿
‍‍- 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