Peds 22 Flashcards
Mandy is a sexually active 16-year-old girl with fever, vomiting, tachycardia, and acute onset progressive diffuse abdominal pain. She also reports dysuria and dyspareunia. On exam she has cervical motion tenderness and purulent cervical discharge.
What’s the most likely dx?
What labs do you order?
Pelvic inflammatory disease
- Urine or serum hCG
- UA, urine culture
- urine NAATs for CT/GC
- saline microscopy
- ESR/CRP
A 16-year-old female with a history of irregular menses presents to the ED with severe abdominal pain. She has regular unprotected sexual intercourse with multiple male sexual partners. She has experienced fevers, nausea, vomiting, right shoulder pain and reports no vaginal bleeding or discharge. Vitals are T 38.0 C, BP 90/60 mmHg, P 120 bpm, R 20 bpm. Qualitative ß-hCG is positive, and hemoglobin is 7 g/dL. Physical exam reveals that she has difficulty answering questions due to pain. Auscultation of the chest is notable for tachycardia, a murmur, and clear lungs bilaterally. The abdomen is rigid with tenderness throughout, but more so in the right lower quadrant. There is guarding and rebound tenderness. On pelvic exam, there is cervical motion tenderness but no bleeding or masses noted. What is the most likely diagnosis?
A. Appendicitis B. Fitz-Hugh-Curtis syndrome C. Hepatitis D. Pelvic inflammatory disease E. Ruptured ectopic pregnancy
E. Ruptured ectopic pregnancy
A 16-year-old female presents with acute onset of diffuse abdominal pain with intermittent sharpness in the epigastrium that radiates to her back. She has had some episodes of vomiting and has a low grade fever. She is sexually active and has used alcohol in the past. Which of the following is most likely to present with epigastric abdominal pain?
A. Appendicitis B. Ectopic pregnancy C. Ovarian torsion D. Pancreatitis E. Urinary tract infection
D. Pancreatitis
A 16-year old female presents to the ED with abdominal pain. Upon questioning, the patient notes that the pain is consistently in the RLQ without radiation. She reports no dysuria, hematuria, diarrhea, or hematochezia. She has a history of multiple sexual partners and inconsistent condom use. She does not use any other contraceptive measures. She believes her last menstrual period was 3 weeks ago, but she is unsure. She has no history of abdominal or pelvic surgeries. Her temperature is 100.8 F, pulse is 85 bpm, respiratory rate is 12 bpm, and blood pressure is 110/70 mmHg. Her abdominal exam is notable for involuntary guarding, tenderness to palpation in the RLQ without rebound tenderness, and no CVA tenderness. Her pelvic exam is notable for cervical motion tenderness with some discharge. What is the best NEXT step in management?
A. Abdominal CT B. Cervical cultures C. Empiric antibiotics D. Pelvic ultrasound E. Pregnancy test
E. Pregnancy test
A 15-year-old female presents with three hours of abdominal pain and two episodes of nonbilious, nonbloody vomiting. She rates her pain at 8/10 and describes it as constant, diffuse, but most severe in her periumbilical region. It is worse with coughing and moving. She has never had pain like this before and has had no appetite since the pain started. She is sexually active with her boyfriend of three months, always uses condoms, and has not been tested for STIs. She is due to start her menstrual cycle next week. Vitals: 37.9 C, HR 100 bpm, BP 120/85 mmHg, RR 14 bpm. On exam, she exhibits involuntary guarding, mild rebound tenderness, and tenderness to palpation between her right anterior superior iliac spine and umbilicus. On pelvic exam, she reports tenderness when attempting to palpate her right adnexa, but there are no masses and no cervical motion tenderness. Her WBC and CRP are both mildly elevated. Based on the information above, what is the most likely diagnosis?
A. Appendicitis B. Cholecystitis C. Ectopic pregnancy D. Ovarian torsion E. Pelvic inflammatory disease
A. Appendicitis
A 16-year-old homeless female presents with low-grade fever and abdominal pain. The patient reports recent unprotected sex. Abdominal examination reveals tenderness to palpation in the lower abdominal region, but no masses are felt. Pelvic examination reveals whitish cervical discharge and cervical motion tenderness. The discharge is sent for culture, and a pregnancy test is negative. What is the next best step in management?
A. Abdominal CT B. Arrange for hospitalization C. Begin oral antibiotics and IM antibiotics and treat her partner D. Pelvic ultrasound E. Surgical consult
B. Arrange for hospitalization
This patient has signs and symptoms of PID. Cervical discharge should be tested for gonorrhea and chlamydia and sent for culture. As she is a homeless patient, she is at high risk for failure to complete her antibiotic course. Given the deleterious sequelae of incompletely treated PID, she should be hospitalized in order to ensure a full course of treatment.
What is the tx for gonorrhea +/- chlamydia?
Ceftriaxone 500mg IM single dose
If can’t r/o chlamydia, also give doxycycline 100mg BID x7 days OR azithromycin 1g PO once
What is the f/u plan for a patient who tests positive for an STI?
- Make sure sexual partners are seen and treated
- abstain from sexual intercourse for 7 days
- f/u in 72 hours for clinical improvement (hospitalize is no improvement)
- retest in 3 months
