Snapshot A sexually active 14-year-old girl is brought to the emergency department because of acute bilateral lower quadrant abdominal pain. She has a history of multiple sexual partners. Her temperature is 102°F (38.9°C). Bimanual pelvic exam shows cervical exudate and tenderness on cervical motion. Her β-HCG is within normal limits. Sonogram shows thickened fallopian tubes with fluid in the posterior cul-de-sac. Introduction Clinical definition pelvic inflammatory disease (PID) is an infection of the upper female genital tract that is often polymicrobial may include endometritis salpingitis tubo-ovarian abscess pelvic peritonitis Epidemiology incidence US incidence 750,000 cases annually demographics sexually active women 15-29 years of age location upper female genital tract risk factors age < 25 years of age risky sexual behavior earlier age at first intercourse increasing number of sex partners Pathophysiology pathobiology usually polymicrobia likely microbes Neisseria gonorrhoeae Chlamydia trachomatis anaerobes gram-negative rods Streptococcus agalactiae Gardnerella vaginalis Haeomphilus influenza Cytomegalovirus Mycoplasma genitalium pathoanatomy ascending infection of microbes from endocervix to upper genital tract Associated conditions other sexually transmitted diseases (e.g., chlamydia, chancroid, herpes, etc.) Prognosis may recur prognostic variable negative salpingitis multiple recurrence Presentation Symptoms may be asymptomatic if subclinical primary symptoms lower abdominal or pelvic pain chills dyspareunia dysuria nausea or vomiting Physical exam inspection fever abnormal cervical discharge or bleeding cervical friability abnormal vaginal odor ecchymosis and swelling diffuse tenderness right upper quadrant tenderness perihepatic space may be involved provocative tests cervical motion tenderness also known as “chandelier test” adnexal tenderness uterine tenderness Imaging Ultrasonography indication if diagnosis is uncertainty with physical exam and clinical history view transvaginal findings thickened fluid-filled tubes with or without free pelvic fluid with or without tubo-ovarian abscess Studies Labs may test positive for sexually transmitted diseases Neisseria gonorrhoeae Chlamydia trachomatis Diagnostic criteria positive physical exam findings uterine tenderness adnexal tenderness cervical motion tenderness Differential Ectopic pregnancy positive pregnancy test Appendicitis PID typically presents with bilateral abdominal tenderness Treatment Medical cephalosporin plus doxycycline (outpatient) indications clinical findings of PID alone is often enough to indicate treatment of PID uncomplicated PID cefoxitin plus doxycycline indications for intravenous medication or hospitalization uncertain diagnosis tubo-ovarian abscess unstable patient failure to respond to outpatient treamtment within 72 hours Complications Infertility 15% after one episode of PID Ectopic pregnancy 10x risk after PID Fitz-Hugh-Curtis syndrome clinical definition infection of liver capsule with multiple peritoneal adhesions incidence 10% of women with PID
QUESTIONS 1 of 2 1 2 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.GN.13.49) A 20-year-old G0 woman presents with 4 days of fever and pelvic pain. The patient has had these symptoms before but not to this extent. Last night, she even experienced an episode of emesis from her discomfort. The patient is a yoga instructor, does not smoke or drink alcohol, is a vegan, and is sexually active with both men and women. Her temperature is 102°F (38.9°C), blood pressure is 124/84 mmHg, pulse is 110/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical examination reveals cervical motion tenderness, left adnexal fullness, and the finding in Figure A. Laboratory values are ordered as seen below.Hemoglobin: 13 g/dLHematocrit: 39%Leukocyte count: 19,500/mm^3 with normal differentialPlatelet count: 297,000/mm^3An ultrasound is performed as seen in Figure B. Which of the following is the most appropriate initial treatment for this patient? Review Topic | Tested Concept QID: 103412 FIGURES: A B Type & Select Correct Answer 1 Cefoxitin and doxycycline 17% (6/35) 2 Ceftriaxone and azithromycin 71% (25/35) 3 Levofloxacin and metronidazole 0% (0/35) 4 Metronidazole 3% (1/35) 5 Surgical drainage 3% (1/35) L 3 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1