“I’ve had increasing pain in my stomach for almost two days now and I think that I have a fever. I’ve also had occasional chills and I threw up once last night. I think that I have a virus of some kind.”
HPI
Ms. P.C. is a 19-year-old white female who reports a 2-day history of lower abdominal pain, nausea, emesis + 1, and a heavy, malodorous vaginal discharge. She states that she is single, heterosexual, and that she has been sexually active with only one partner for the past eight months. She has no previous history of genitourinary infections or sexually transmitted diseases. She denies IV drug use. Her LMP ended three days ago. Her last intercourse (vaginal) was eight days ago, and she states that they did not use a con- dom. She admits to unprotected sex “every once in a while.” She noted an abnormal vaginal discharge yesterday and she describes it as “thick, greenish-yellow in color, and very smelly.” She denies both oral and rectal intercourse. She does not know if her partner has had a recent genitourinary tract infection, “because he has been away on business for five days.”
PMH
Seizure disorder + 3 years, Migraine headaches 1–2 per month for 21⁄2 years, Denies any pregnancies, elective abortions, and miscarriages
FH
Both parents and older sister are “all healthy as far as I know”
SH
• Denies nicotine, caffeine, and recreational drug use
• Occasional glass of wine or wine cooler
• Uses birth control pills and occasional use of a condom for “double protection,” but no diaphragms, IUDs, or spermicides
• No routine medical care because she “doesn’t have a good health insurance plan yet”
• Denies that sexual partner sleeps with other women
• Admits to vaginal douching, but only “once in a while”
ROS
Occasional painful menses
Meds
• Phenytoin 100 mg po TID • Sumatriptan 50 mg po PRN • Acetaminophen ES PRN for headaches and menstrual cramps • Ortho-Novum1/3528
Question 1. Identify two risk factors that predispose this patient to PID.
Allergy
PCN → allergy as a child, NSAIDs → GI intolerance
PE and Lab Tests
General: Alert, WDWN white female with moderate-to-severe lower abdominal pain, appears to be her stated age, Pain index at 7–8/10
VS:
Skin: Diffuse pallor, Warm and slightly diaphoretic with no lesions or rashes
HEENT: Head is NC/AT, PERRLA, pupils at 3 m, EOMI, TMs intact, Nares are clear bilaterally, Throat shows no erythema, exudates, or lesions, Mucous membranes in oropharynx are moist
Neck/LN: Neck supple and non-tender, Shotty cervical and submandibular lymphadenopathy, Thyroid not enlarged
Chest: Good, clear breath sounds throughout
Breasts: Mild fibrocystic changes, otherwise unremarkable
Cardiac: Sinus tachycardia, Normal S1 and S2, No S3 or S4 heard, No murmurs
Abd: Guarding of both right and left lower quadrants with palpation, (+) bilateral adnexal tenderness, Bowel sounds present in all quadrants, (-) HSM and bruits
Genit/Rec
• Vulva: moderate erythema with no lesions visible
• Vagina: large amount of thick, malodorous, yellow-green discharge and moderate erythema with no lesions visible
• Cervix: moderate-to-severe erythema and significant yellow-green discharge around os
with no lesions visible
• (+) cervical motion tenderness
MS/Ext: Pedal pulses 2+, Shotty inguinal adenopathy, No lesions or rashes, Normal ROM, Muscle strength 5/5 throughout
Neuro: A&Ox3, CNs II–XII intact, Sensory and motor levels intact, (-) Babinski, DTRs 2+, Normal gait
Question 2. Can a diagnosis of PID be made based on the clinical manifestations of the illness at this point? Why or why not?
Laboratory Test Results
Question 3. What does the abnormal white blood cell differential suggest?
Question 4. Define “band cells” and describe the pathophysiology that underlies their abnormal number in the blood.
Question 5. What is the significance of this patient’s ESR and CRP?
UA
Question 6. What is the significance of this patient’s urinalysis?
Microscopic Examination of Vaginal Discharge: (-) yeast or hyphae, (-) flagellated microbes, (+) white blood cells, (+) gram-negative intracellular diplococci
Question 7. Which type of infection is suggested by microscopic examination of the vaginal discharge and other laboratory tests: chlamydial, gonococcal, or mixed chlamydial/gonococcal?
Question 8. Should this patient be hospitalized and promptly given IV antibiotics? Why or why not?
HPI: Patient’s Sexual Partner
Upon return from his business trip, the patient’s sexual partner, Mr. Y.V., presented to a health clinic with complaints of “several days of painful urination and an increasing amount of a thick, yellowish fluid from my penis.” He admits to being sexually active with three frequent partners and to unprotected sex at least twice in the past two weeks. His PMH includes two episodes of urethritis secondary to an STD in the last two years. With the exception of a thick urethral discharge that was positive for WBC and showed gram-negative intracellular diplococci, the patient’s limited physical examination was unremarkable.
Question 9. Based on this sexual partner’s history of present illness, identify one more very significant risk factor for PID.
Patient Case #2
Patient’s Chief Complaints
“It hurts to urinate and it seems that I am going to the bathroom every hour, if not more. I was up again last night at least a half-dozen times to use the bathroom and this has been going on now for several days.”
History of Present Illness
Mr. E.D. is a 63-year-old retired pharmacist who visits the family practice clinic for a routine follow-up for hypertension. He complains of a three-day history of dysuria, increased urinary frequency, and nocturia. He denies fever, chills, and recent sexual activity. On examination, his temperature is 99.5°F, pulse 75 and regular, respiratory rate 16 and unlabored, and blood pressure 135/85. He does not appear acutely ill and is in no apparent distress. Examination of the abdomen was normal. A digital rectal exam revealed a moderately enlarged, firm, non- tender prostate gland.
Past Medical History
• Historyof“heartattack”perpatientreportapproximately15yearsago(norecordsavailable)
• Sciatica on right side + 10 years following lifting injury; several steroid floods and laminectomy with no long-term pain relief
• Hepatitis B carrier detected at age 53
• HTN diagnosed at age 56
• BPH + 5 years
• UTI and/or prostatitis, 3 episodes in last 5 years, last attack 20 months ago
• Prostatic calculi detected with ultrasonography 4 years ago
Family History
• Father died from prostate cancer at age 77
• Mother currently undergoing treatment for ovarian cancer at age 84
Social History
• Divorced and lives alone
• Previous smoker of 1⁄2 to 1 ppd for 35 years, quit 8 years ago
• Has 2–4 beers on weekends
• May be unreliable in keeping follow-up appointments because he states “I don’t like doctors”
Medications
Atenolol 25 mg po QD, HCTZ (25 mg) ? triamterene (37.5 mg) po QD, Oxycodone (4.88 mg) + aspirin (325 mg) 2 tablets po PRN
Allergies: NKDA
Clinical Workup
Symptoms suggest that cystitis, urethritis, and/or prostatitis are the most likely diagnoses. The patient was immediately referred to a urologist at the clinic who conducted a 3-cup bacterial localization test, CBC, blood culture for bacteremia, and renal function studies.
3-Cup Bacterial Localization Results
Other Laboratory Test Results
Question 1. Why did the primary care provider ask the patient if he was sexually active?
Question 2. Based on the results of the 3-cup bacterial localization test, is urethritis and/or cystitis associated with prostatitis in this patient?
Question 3. Cite three major risk factors that may play key roles in the development of prostatitis in this patient.
Question 4. Which antibiotic regimen do you think the urologist prescribed for this patient?
Question 5. Why was hospitalization considered unnecessary at this point in the clinical course of the illness?
Clinical Course
The patient returns 48 hours later with continued dysuria. He has also noted severe urgency and greater difficulty with passage of urine. “I hardly peed at all since I saw you last and I feel worse.” On examination, temperature was 100.8°F and the suprapubic area was tender. A repeat BUN was 35 mg/dL and serum creatinine concentration was 2.1 mg/dL.
Question 6. What is causing the progressive nature of this condition?
Question 7. Provide at least four management approaches that are appropriate at this time.
Sample Solution
