CCS Interactive Case 15

Question 1

22 y/o F presents to ED w/lower abdominal and pelvic pain worsened by movement and intercourse, along with fever, chills, N/V, vaginal discharge. LMP 3 weeks ago, only medication is OCP, has unprotected intercourse w/boyfriend. Vitals demonstrate fever (102.4F) and tachycardia (102).

DDx?

Answer 1

PID

Appendicitis, ectopic pregnancy, septic abortion, pyleonephritis, ovarian cyst, enteritis

Question 2

Exam?

Answer 2

Abdominal, rectal, pelvic exams

Question 3

Cervical motion tenderness, bilateral adnexal tenderness, mild purulent discharge at the cervical os

Next steps?

Answer 3

CBC, BMP, pregnancy test, cervical gram stain and G&C cultures, UA, urine culture and sensitivity, pap smear, HIV, syphilis testing

Question 4

Dx confirms PID due to gonococcal infection

ABX?

Answer 4

IV cefoxitin + IV doxycyline

Question 5

Criteria for inpatient management of PID?

Answer 5

Fever>102.2, severe abdominal pain
Inability to take PO (N/V), lack of response to PO ABX, non-adherence
Pregnancy
Pelvic/tubo-ovarian abscess

Question 6

Inpatient ABX regimen

Answer 6

IV cefoxitin or IV cefotetan + IV or PO doxycyline

IV cindamycin + IV gentamycin

IV ampicillin-sulbactam + IV or PO doxycycline

Oral doxycycline preferred initially if able to tolerate PO

Switch to PO after 24 hours of sustained clinical improvement

Question 7

Outpatient ABX regimen

Answer 7

Ceftraixone IM (1 dose) + doxcycline PO for 14 days

Cefoxitin IM (1 dose) + probenecid PO (1 dose) + doxy x 14 days

May add metronidazole if suspected BV, trichomonas, pelvic abscess, or recent gyne instrumentation

F/u within 72 hours to ensure improvement

Question 8

Counseling

Answer 8

Treat partners
Patient counseling
Contraception counseling
Medication compliance
Safe sex counseling
Smoking cessation

Question 9

Sequence?

Answer 9

Exam: focused (general, skin, lymph node, HEENT/neck, chest/lung, CV, abdominal, genital rectal, ext/spine)
Order: IV access, CBC w/diff, BMP, Beta-hCG, UA, UCx, cervical gram stain, cervical gonococcal culture, cervical chlamydia culture, Pap smear, ESR, VDRL, HIV (ELISA), blood culture (all stat)
Advance clock to obtain results of cervical gram stain. Note negative beta-HCG, Gram negative diplococci on gram stain
Location: transfer to ward
Order: IV (continuous) cefoxitin, doxycycline, phenergan, Tylenol, NS, also morphine IV x1, NPO, bedrest w/bathroom privileges
Clock: advance 12-24 hours
Request interval f/u and abdominal/genital exam until patient improves
Cancel phenergan, morphine, NPO, bedrest
Order normal diet, ambulate at will
Advance clock 12-24 hours and request interval f/u, abdominal/genital exams until sustained clinical improvement for 24 hours
Order: doxycyline oral continuous, counseling
Cancel IV fluids, cefoxitin, doxy, vitals
Location to home
Schedule appt in 7 days
Case ends
Final orders: none
Dx: acute PID