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This is a 23-year-old sexually active female, G0P0, LMP 3 weeks ago on OCPs who presents with midline suprapubic abdominal pain x 5 days, now with LLQ localization of less than 24 hours duration. The pain is worse with standing and movement; she reports chills/sweating, poor appetite, nausea, and dizziness; she denies abnormal vaginal bleeding and lower/upper urinary-tract symptoms. PE reveals an ill-appearing, her vital signs reveal fever of 101, tachycardia, and hypotension (P 126, BP 88/56), with intermittent tachypnea secondary to pain, pelvic exam demonstrates foul vaginal discharge with purulence draining per cervical os, a normal-size uterus, cervical-motion tenderness, and fullness with marked tenderness of the left adnexa.

1- Discuss the questions that would be important to include when interviewing a patient with this issue.

Important assessment questions will include: To review onset, duration, course, and quality of pain. Determine pain rating on a 10­point scale. To review the pattern of pain, LMP, surgical Hx, and/or recent history of dyspareunia or dysmenorrhea that suggests pelvic pathology.

Other questions include: history of physical abuse, what type of contraception is used; specifically evaluate for an intrauterine device (IUD), history of sexually transmitted infection (STI) and PID. Evaluate for new partner and/or if partner is experiencing any symptoms. Medication list, alcohol and/or drugs use. Whether patient is a smoker.

2- Describe the clinical findings that may be present in a patient with this issue.

Tubo-ovarian abscess (TOA) is one of the late complications of pelvic inflammatory disease (PID). Patients typically present with fever, elevated white blood cell count, lower abdominal-pelvic pain, heavy vaginal discharge with an unpleasant odor, abnormal uterine bleeding, especially during or after intercourse, or between menstrual cycles, pain or bleeding during intercourse, and/or painful or difficult urination (Mayo Clinic, 2016).

3- Are there any diagnostic studies that should be ordered on this patient? Why?

Laboratory studies will include those to rule out pregnancy, infection, pelvic, and abdominal pathology. Complete blood count (CBC) with differential, CMP, HcG urine, urinalysis, blood culture and sensitivity, serum lactic acid, RPR, N. Gonorrhoeae/chlamydia swab/PCR, serologic studies for human immunodeficiency virus (HIV) infection, and pelvic ultrasound. Pelvic ultrasound evaluation is the recommended imaging modality of choice when TOA is suspected. It will show multilocular complex retro-uterine/adnexal mass with debris, septations, and irregular thick walls, commonly bilateral, and there may be echogenic debris in the pelvis (Buttaro, Trybulski, Bailey & Sandberg-Cook, 2013).

4- List the primary diagnosis and three differential diagnoses for this patient. Explain your reasoning for each.

Primary Diagnosis:

Tubo-ovarian abscess: Signs and symptoms of tubo-ovarian abscess include: Hx of STI’s, gradual development of pain, fever, cervical discharge on speculum examination, cervical motion tenderness, and adnexal tenderness on bimanual pelvic examination (Cash & Glass, 2014). Mrs. Phillips pelvic exam demonstrates foul vaginal discharge with purulence draining per cervical os, cervical-motion tenderness, and fullness with marked tenderness of the left adnexa. The pelvic ultrasound revealed a left tubo-ovarian abscess.

Differential diagnoses:

1- PID: An abrupt onset of acute lower abdominal pain following menses has been considered the characteristic presenting symptom of PID, but symptoms of this infection can also be very mild and nonspecific. Frequently reported symptoms include abdominal, pelvic, and low back pain; abnormal vaginal discharge; intermenstrual or postcoital bleeding; fever; nausea and vomiting; and urinary frequency. Pelvic pain is usually exacerbated by the Valsalva maneuver, intercourse, or movement (Schuiling & Likis, 2017). Mrs. Phillips pelvic exam demonstrates foul vaginal discharge with purulence draining per cervical os.

2- Ectopic pregnancy: Pelvic and abdominal pain and unexplained vaginal bleeding are the primary symptoms experienced by most women with ectopic pregnancy. The pain may be described as vague, sharp, diffuse, or unilateral. The woman may have had a time of amenorrhea, and pregnancy may or may not already be diagnosed. Physical findings associated with ectopic pregnancy include cervical motion tenderness, a uterus that is not enlarged, adnexal mass, and adnexal tenderness (Schuiling & Likis, 2017). Upon physical examination Mrs. Phillips had cervical-motion tenderness, and fullness with marked tenderness of the left adnexa.

3- Ovarian torsion: Distinguished typical characteristics include: Sudden onset pain, severe, often unilateral; associated nausea or vomiting (Schuiling & Likis, 2017). Mrs. Phillips presents with midline suprapubic abdominal pain x 5 days, now with LLQ localization of less than 24 hours duration. The pain is worse with standing and movement; she reports chills/sweating, poor appetite, nausea, and dizziness. The pain is rated 9 on a 10­point scale.

5- Discuss your management plan for this patient, including pharmacologic therapies, tests, patient education, referrals, and follow-ups.

Hospitalization will be require to provide IV access and surgical evaluation. Initial treatment will require antibiotic therapy. When TOA is present, many health care providers use clindamycin or metronidazole with doxycycline for continued therapy because the combination provides effective anaerobic coverage. Patients receiving parenteral therapy should show substantial improvement within 72 hours after therapy is initiated. Those who do not receive parenteral therapy usually require further diagnostic evaluation or surgical intervention (Buttaro, Trybulski, Bailey & Sandberg-Cook, 2013).

Radiological guided drainage or surgery may be required in patients resistant to antibiotic treatment. Drainage may be performed from an endovaginal, trans-gluteal, or trans-abdominal approach, dependent on patient and operator preference. An oophorectomy can also be performed when risk of rupture or abscess rupture (Buttaro, Trybulski, Bailey & Sandberg-Cook, 2013).. Follow up with gynecologist to monitor after surgery.

References:

Buttaro, T., Trybulski, J., Bailey, P., Sandberg-Cook, J. (2013). Primary Care, 4th Edition. [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/boo…

Cash, J. C. & Glass, Ch. A. (2014). Family Practice Guidelines, 3rd Edition. [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/boo…

Mayo Clinic. (2016). Pelvic inflammatory disease (PID). Retrieved from: http://www.mayoclinic.org/diseases-conditions/pelv…

Schuiling, K.D & Likis, F.E. (2017). Women’s Gynecologic Health, 3rd Edition. [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/boo…

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