Full Answer Section

• Sexual history: multiple sexual partners, inconsistent condom use

Past Medical History:

• Seasonal allergies
• Appendectomy at age 10

Medications:

• Flonase nasal spray daily
• Loratadine 10mg daily

Allergies:

• No known drug allergies

Social History:

• Single, sexually active
• Smokes occasionally
• Moderate alcohol consumption
• Lives in an urban area

Family History:

• Non-contributory

Physical Exam

General Appearance:

• Appears ill, anxious
• Vital signs: T 37.2°C, HR 98 bpm, RR 18/min, BP 120/80 mmHg

Abdomen:

• Tenderness in the lower abdomen, especially in the suprapubic region
• Mild guarding

Pelvic Exam:

• Cervix: erythematous, friable, with purulent discharge
• Uterus: slightly tender, normal size and shape
• Adnexa: tender to palpation bilaterally

Assessment

Differential Diagnosis:

• Pelvic Inflammatory Disease (PID): Most likely diagnosis given the patient’s symptoms, including lower abdominal pain, dysuria, and purulent vaginal discharge.
• Cervicitis: Inflammation of the cervix, often caused by sexually transmitted infections (STIs).
• Endometritis: Inflammation of the endometrium, often a complication of PID.

Primary Diagnosis: Pelvic Inflammatory Disease (PID)

Plan:

1. Diagnostic Tests:
   • Laboratory Tests:
     • Cervical culture for Neisseria gonorrhoeae and Chlamydia trachomatis
     • Urine culture
     • Complete blood count (CBC)
     • Pregnancy test
2. Treatment:
   • Antibiotics:
     • Ceftriaxone 250 mg IM single dose
     • Doxycycline 100 mg orally twice daily for 14 days
   • Pain Management:
     • Over-the-counter pain relievers, such as ibuprofen or acetaminophen
   • Sexual Health Counseling:
     • Advise patient to abstain from sexual activity until completion of treatment
     • Encourage partner notification and treatment
     • Discuss importance of safe sex practices, including consistent condom use

Follow-up:

• Schedule a follow-up visit in 2 weeks to assess symptom resolution and treatment response.
• Consider repeat testing for STIs in 3 months.

By promptly diagnosing and treating PID, we can prevent complications such as infertility and chronic pelvic pain. Early intervention and appropriate treatment are essential for optimal outcomes.