Ms. Decker is a 22-year-old woman who was incarcerated in the county jail last week. Yesterday she submitted a Health Service Request form complaining of abdominal pain for the past week and a half.
She is called to Nurse Sick Call this morning and describes the pain as sharp in nature, located in the suprapubic region, rated 8/10, and constant; but it does not radiate. She also complains of lower back pain. Her last menstrual period was almost three weeks ago. Her cycles are noted to be regular and last approximately five days. She states she has never experienced this type of pain before, but prior to incarceration, having sexual relations “hurt,” and this was something new. She has been diagnosed with sexually transmitted infections twice in the last year. She believed her boyfriend when he told her he was not cheating on her – the STIs she had were from dirty toilet seats. The pain is exacerbated by movement, and she states nothing makes it better. She states prior to incarceration she was in a monogamous relationship with her boyfriend of two years, and they do not use any form of contraception.
The patient’s ROS is positive for suprapubic pain, low back pain, dyspareunia, nausea, fever, chills, frequency, and yellow-white vaginal discharge. The ROS is negative for vomiting, diarrhea, urgency, dysuria, anorexia, chest pain, SOB, headaches, dizziness, and abnormal vaginal bleeding.
No known drug allergies; no known food allergies.
Vitals: T 99.9°F; P 67; R 18; BP 127/86; SpO2 98%; Pain 8/10; HT 5’6”, WT 200 lbs, BMI 32.27.
Alert, oriented x 4, ill-appearing obese female lying in the right lateral decubitus position, in moderate distress secondary to pain.
Psychiatric: Appropriate mood and affect.
Skin, Hair, and Nails: Warm and dry, color appropriate for ethnicity. No visible rash; no abnormal findings on hair or nails.
Lungs: Clear to auscultation without adventitious sounds; good air movement throughout.
Cardiac: S1, S2, RRR, without murmurs, rubs or gallops.
Abdomen: Normoactive bowel sounds, soft, obese, and non-distended x 4, ++ pain with palpation right lower quadrant, no guarding, no rebound, no masses appreciated; Psoas, Rovsing, and Obturator signs all negative.
Correctional Nurse Actions
Abdominal pain with palpation ++ requires a referral to the provider on-site, which the nurse does and Ms. Decker is seen by the provider that day.
The Provider seeing Ms. Decker conducted an internal exam, including speculum and bi-manual examinations, which was performed with a chaperone present in the room at all times.
Genital/Internal Exam Findings: Normal external genitalia without rash, ulcerations, or abnormal lesions. Speculum exam notes moist, pink, vaginal walls with mild erythema, frothy, thin, yellow-white discharge pooled in the posterior fornix noted; no lesions or ulcerations. Cervix is erythematous, with noted discharge. Cervical motion tenderness (++pain!) noted. Bimanual exam notes positive bilateral adnexal tenderness to palpation, with no palpable masses appreciated. No palpable inguinal lymphadenopathy.
Differential Diagnoses for Ms. Decker
Ruptured ovarian cyst/ovarian cyst is a common noninfectious cause of pelvic pain with a variable presentation. This often presents with severe unilateral lower abdominal and pelvic pain (especially with rupture) with nausea and vomiting. This is often misdiagnosed as acute appendicitis when a patient presents with acute right-sided abdominal pain with nausea and vomiting. In this patient’s case, the vaginal discharge and adnexal tenderness to palpation make this diagnosis unlikely.
Ectopic pregnancy always needs to be ruled out in a young, sexually active female with lower abdominal pain and vaginal bleeding. Patients can have a variable presentation but often present with lower quadrant tender to palpation with or without associated vaginal bleeding and a palpable mass, if unruptured. The patient may have adnexal tenderness to palpation with an ectopic pregnancy; however, with her last menstrual period noted to be 3 weeks ago and usual for her, a negative pregnancy test today, and a pelvic exam yielding abnormal discharge and excruciating cervical motion “tenderness” , this diagnosis is less likely.
Appendicitis typically presents with periumbilical or epigastric pain that localizes to the right lower quadrant, with associated fever, chills, and anorexia. The physical examination of a patient with acute appendicitis would not necessarily yield an abnormal vaginal exam unless it was a comorbidity. It would, however, yield guarding and possible peritoneal signs, with or without a positive Psoas, Rovsing, or Obturator sign, which were negative for this patient.
Pelvic Inflammatory Disease always needs to be ruled out in a sexually active female with associated fever, chills, abdominal pain, and dyspareunia and a history of a previous STI. With the patient’s vaginal exam noting abnormal discharge, positive adnexal tenderness to palpation and cervical motion tenderness, this would rank highest on a list of differential diagnoses.
Most Likely Diagnosis
Pelvic Inflammatory Disease (PID). Lower abdominal or suprapubic pain in a sexually active female with associated vaginal discharge is highly suggestive of PID. This is a clinical diagnosis strongly supported with her positive adnexal tenderness to palpation. Cervical motion tenderness, also known as a positive chandelier sign, may be noted on exam as well. The risk of PID is even higher in a patient with a history of STIs.
Pathophysiology of PID
PID is a cluster of disorders, specific to women, characterized by salpingitis and oophoritis. PID results from a vaginal or cervical infection that spreads to the upper genital tract and is common in sexually active women under age 30. Typically, the pathophysiology of PID is an untreated STI. Neisseria gonorrhoeae (N. gonorrhoeae) and Chlamydia trachomatis (C. trachomas) are associated with a majority of cases. However, an STI is not the sole cause of PID. Translocation of gut bacteria has been reported as a rare cause of PID and tubo-ovarian abscess in women who are not sexually active. There is a demonstrated relationship between PID and Bacterial Vaginosis (BV), but it is not yet clearly understood. It is known that BV alters the cervical mucosa, facilitating an ascending infection from an STI.
Urine hCG to rule out pregnancy
UA to rule out UTIs
Urine NAAT for C. trachomatis and N. gonorrhoeae
Microscopic exam (vaginal wet prep) to screen for bacterial vaginosis, trichomonas, and fungal infection
CBC to rule out infection and anemia
All tests were normal/negative, except her urine NAAT test, which came back positive for chlamydia. Her test was negative for gonorrhea.
PID is a clinical diagnosis. In an otherwise healthy young female who will adhere to and tolerate oral medication, treatment cover the most likely organisms (C. trachomatis and N. gonorrhoeae) is indicated. Medication was initiated for a presumptive diagnosis of PID with one dose of ceftriaxone 500 mg IM now and doxycycline 100 mg BID for 14 days and metronidazole 500 mg BID for 14 days.
The patient was scheduled to return to Provider Sick Call for in 1 week and was told to contact medical if she had any worsening of her condition, including pain in a different location or with different characteristics, or fever or chills. She was advised to inform her sexual partner of her diagnosis so he could seek evaluation and treatment. It was also emphasized that it was important to finish all the medication if she was released before the 14 day prescriptions were completed. Ms. Decker verbalized an understanding of all.
PID and complications that can arise if untreated
Safe sex precautions
Methods of contraception
Notification of sexual partner
Importance of medication compliance
The patient’s HCG was negative. She was treated for suspected PID possibly caused by C. trachomatis, with additional coverage for potential coinfection with N. gonorrhea based on her initial clinical presentation. Her urine NAAT test came back positive for chlamydia. Her test was negative for gonorrhea and an HIV screen was negative. The antibiotics prescribed for PID also covered the chlamydia infection, so prescribing another antibiotic was not necessary. The patient was in a monogamous relationship with her boyfriend. Armed with the patient education regarding STIs discussed with her in our encounter, she contacted her boyfriend and when she advised him of her diagnosis (and that she knew it wasn’t from a toilet seat), he disclosed that he had had several unprotected sexual encounters with at least three other females over the past 6 to 9 months. The patient shared that she and her boyfriend are no longer in a relationship and he sought treatment with his PCP.
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