Monday, June 6, 2011

Intern Report Case Presentation 4.2


Case Presentation by Dr. Deepa Japra


A 25-year-old woman presents to the emergency department with persistent nausea and vomiting for 6 days. She complains of pain in the lower chest and upper abdomen that she rates as a 6/10.  She describes the pain "like a heart beating real hard”, which is constant and throbbing in character. She is unable to tolerate a regular diet and states she vomits everything she eats.  The vomitus is described as white and yellowish without hematemesis.  The patient had a small bowel movement today, which was soft with no gross blood.  She denies any genitourinary symptoms including no polyuria, dysuria, or hematuria. She does describe a vaginal discharge X 6 days. She is sexually active with one partner, and does not use protection.  Her LMP ended 9 days ago. She has also had subjective fevers and chills, and lightheadedness, but without any syncopal episodes. 

Past medical history is significant for genital herpes infection.

VS: BP: 122/75, P: 59, R:18, T: 36.5, O2 saturation 100% on RA

GENERAL:  Pt is conscious, alert, and cooperative
HEENT:  Conjunctivae are pink without pallor, sclera anicteric. Mouth without intraoral lesions.  Pharyngeal soft tissues are normal.
NECK:  Supple. Trachea midline. No thyromegaly or lymphadenopathy.
RESPIRATORY:  Clear symmetric breath sounds. Good air exchange in all lung fields. No accessory muscle use.
CARDIOVASCULAR:  Normal S1 and S2.  No S3 or S4 gallops.  No murmurs or rubs.  CHEST WALL:  Nontender.
ABDOMEN:  Soft, nondistended, bowel sounds present. mild discomfort to palpation in the epigastric and suprapubic areas, but there is no guarding, masses or rebound tenderness. 
BACK:  No spinal or paraspinal tenderness. No CVA tenderness.
MUSCULOSKELETAL:  FROM, symmetrical strength, no acutely inflamed joints. SKIN:  No rashes or lesions.
NEUROLOGIC:  No gross focal motor or sensory deficits.
PELVIC EXAM: External genitalia are normal. Slight discharge in vaginal vault, cervical os is closed. Positive cervical motion tenderness. Mild uterine and adnexal tenderness, no masses.

Laboratory Studies are as follows:
CBC: Hb 15.5, Hct 43.1, WBC 9.2, Pl 234
Electrolytes: Na 139, K 3.7, Cl 101, HCO3 26, BUN 21, Cr 1.0, Glu 90, Ca 9.5
Lipase 294
ALT 30, AST 19, Alk Phos 77, TBili .8, DBili .2,
Urine Pregnancy negative
UA: trace glucose, 3+ ketones, 1+ blood, 1+ protein, Positive nitrite, 1+ leukocyte esterase, RBC 2-5, WBC 5-10, 1+ mucus, 1+ bacteria
Rapid HIV negative
Gonorrhea PCR positive, Chlamydia PCR negative

Questions:

Question 1
Which of the following is the greatest risk factor for development of pelvic inflammatory disease?
a.     age
b.     intrauterine device usage
c.     multiple sexual partners
d.     previous PID
e.     sexually transmitted disease status of sexual partner

Question 2:

According to CDC guidelines, which of the following is essential in the diagnostic criteria for empirical treatment of PID?
a.     abnormal cervical or vaginal mucopurulent discharge
b.     history of Gonorrhea/Chlamydia infection
c.     lower abdominal or pelvic pain with cervical motion tenderness or uterine/adnexal tenderness
d.     numerous WBCs on microscopy of vaginal secretions
e.     oral temperature > 38.3 C

Question 3:
In addition to clinical symptoms and physical exam findings, which of the following criteria suggests a confirmed case of PID?
a.     confirmed N. gonorrhea infection in the past
b.     confirmation of ectopic pregnancy on vaginal ultrasound
c.     demonstration of N. gonorrhea in the genital tract
d.     elevated serum WBC count
e.     positive Pregnancy test

Please submit your answers as a comment. Your submission will not immediately post. Answers with a case discussion will post on Friday. If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving’s: Intern Report

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