Patient’s profile
Name: Ms. Nurul Azifa Binti Shafie
Age: 20 years old
Address: Bukit Beruang, Melaka
Occupation: Unemployed
Parity index: Nulliparous
Last menstrual period: 16/5/2016
Date of admission: 5/5/2016
Date of examination: 6/5/2016
Chief Complaints
Lower Abdomen pain for 2 days
History of presenting illness
She was apparently well until past 2 days, when she developed abdominal pain. It is sudden in onset. It is colicky in nature and located at suprapubic region. The does not radiate to other location. Upon admission, the pain score was 7 out of 10. There is no history of similar complaint in past. There is no aggravating factor and relieving factor for the pain. There is no history of fever, dysuria, hematuria, nausea, and vomiting.
The suprapubic pain also associated with vaginal discharge. She started to have vaginal discharge one week prior to the onset of suprapubic pain. It is sudden in onset and it is intermittent. The quantity is scanty and it is white in colour. Patient claimed that the discharge is not foul smelling and not associated with itchiness. Patient is sexually active for the past 1 year. She frequently has sexual intercourse with her boyfriend and her last sexual intercourse was 2 weeks ago. She denied having multiple sexual partner but she was not sure about her boyfriend sexual activity. There is no history of deep dyspareunia and abnormal vaginal bleeding.
Past medical history
Nil
Past surgical history
She had laproscopic appendicectomy done in 2012 at Hospital Tuanku Jaafar, Negeri Sembilan.
Menstrual history
She attained menarche at 11 years old with 4-5 days flow and regular 28-30 days cycle.
There is history of dysmenorrhea.
No oral contraceptives were taken and pap smear not done.
Family history
She is the last child out of 3 siblings
Her father and mother are healthy without any underlying diseases. Her siblings are healthy.
Personal history
She consumed a normal diet. Sleep pattern is normal. Bowel and bladder habit is normal. Patient does not consume alcohol and she is a non-smoker. There is no known allergy toward drug and food.
Social history
She is single and currently living with her parent at Bukit Beruang. She is supported by her parent. Her father is a lorry driver and her mother is a waiter at restaurant. Their income are sufficient to support the family.
Follow up in the ward
At CDS
• Iv Zinecef 750 mg TDS
• IM tramadol 50 mg TDS
• Check FBC, BUSE, B- HCG, Urine biochemical
• Ultrasound abdomen was done
• Observe at CDS
5/6/2017
• Trace B-HCG result stat
• Start on empirical cover for pelvic inflammatory disease
-IV cefuroxime 750 mg TDS
– IV flagyl 500 mg TDS
– Tablet doxycycline 100mg BD
6/6/2017
• Pain is improving pain score is 3 out of 10
• Tablet Azithromycin 1g is prescribed for partner
7/6/2017
• Plan for discharge with tablet Flagyl and tablet doxycycline
• TCA at gynae clinic on September 2017
• Advice patient to practice barrier contraceptive method
Summary
Ms. Nurul Azifa, 20 years old, nulliparous, presented with complaints of suprapubic pain for 2 days associated with vaginal discharge for 1 week. She is sexually active with her boyfriend for the past 1 year. Currently she is stable and the pain is improving .
Physical examination
General examination
On general examination, patient is alert, cooperative and comfortably lying down in supine position. She is moderately built and nourished
Height: 152 cm
Weight: 50 Kg
BMI: 21.6 kg/m2
There is iv cannula on dorsum of left hand.
Vital signs:
• Blood pressure: 112/64 mm Hg
• Pulse: 80 beats/minute
• Respiratory rate: 18 breaths/minute
• Temperature: 37.0 ̊C
There is no pallor over the palms, nail beds and lower palpebral conjunctiva.
There is no cyanosis or clubbing and no icterus over the sclera.
The oral hygiene is good and no sublingual icterus observed.
No thyroid enlargement and no cervical lymph nodes enlargement.
There is no pedal edema.
Abdominal examination
Inspection
Abdomen is not distended and no fullness of flanks.
The umbilicus is centrally placed and inverted.
All quadrants move equally with respiration.
There is 3 scar from previous laparocpic appendicectomy.
There is no visible peristalsis and dilated veins seen on the abdomen and all hernia orifices are intact.
Palpation
Abdomen is soft. There is tenderness at hypogastric area.
There is no palpable mass or organomegaly felt upon abdominal palpation.
Uterus not palpable.
Percussion
All areas of the abdomen are tympanic.
Auscultation
Normal bowel sound heard
Cardiovascular system examination
S1 and S2 heard
No murmur
Respiratory system examination
Normal vesicular breath sound heard
There are no adventitious sounds present
Diagnosis : Pelvic inflammatory disease
Investigation
1. Full blood count (5/6/2017)
Hb – 11.6 g/dL
TWBC – 14.5 x 106 / mm3
Platelet – 412 x 106/ mm3
PCV – 35.6%
2. Renal profile (5/6/2017)
Urea – 4.2
Sodium – 137
Chloride – 105
3. Urine biochemistry (5/6/2017)
pH – 5
Urine specific gravity – 1.017
Leucocytes – negative
Nitrite – negative
Urine protein – negative
Urine glucose – normal
Ketone – 1+
Urobilinogen – normal
Bilirubin – Negative
Red blood cell – negative
4. Ultasound abdomen (5/6/2017)
Both ovary seen
No adnexal mass
Minimum free fluid in pouch of douglas
5. Beta HCG – non reactive
Discussion
Pelvic inflammatory disease is an infection induced inflammation of female upper reproductive tract. Untreated sexually transmitted disease can cause pelvic inflammatory disease can lead to pelvic inflammatory disease. In this patient, she had history of whitish vaginal discharge before the onset of suprapubic pain. This suggest that the patient had vaginal infection before the onset of pain. Besides that the patient also has risk factor for sexual transmitted disease which is unprotected pre-marital.
In acute case of pelvic inflammatory which is less than 30 days duration, it is caused by spontaneous ascension of microbes from the cervix or vagina to the endometrium, fallopian tubes, and adjacent structures. In all cases of pelvix inflammatory disease, more than 85% of infection are due to sexually transmitted cervical pathogens or bacterial vaginosis associated microbes[1]. The most common organism that lead to pelvic inflammatory disease are Chlamydia trachomatis and Neisseria gonorrhoea. Other organisms that can cause pelvic inflammatory disease are gram positive and negative anaerobic organisms and gram positive and negative rods and cocci which are found in high levels in women with bacterial vaginosis[2].
Pelvic inflammatory has wide range of signs and symptoms. The most common symptoms in a patient are lower abdominal pain, pelvic pain, irregular menstrual bleeding, painful sexual intercourse, abnormal vaginal discharge, and fever. Besides that, the doctor can found lower abdominal tenderness which usually bilateral, adnexal tenderness on bimanual vaginal examination, and cervical motion tenderness on bimanual examination[3].
The wide variation of symptoms and signs associated with pelvic inflammatory disease make diagnosing it difficult. There is criteria which have been developed for diagnosing pelvic inflammatory disease. However, empirical treatment can be initiated if one or more criteria is present[4]:
I. Cervical motion tenderness
II. Uterine tenderness
III. Adnexal tenderness
Since the pelvic inflammatory disease is the result sex transmitted disease, vaginal swab can be done. Testing for gonorrhoea and chlamydia in the lower genital tract is recommended since positive result supports the diagnosis of PID[5]. Since this disease involve inflammation of female reproductive tract, level of ESR and C reactive protein can also be measured but these are non specific because inflammation at other places in the body will also lead to increase these parameter[6]. Since ectopic pregnancy is one of the differential diagnosis, B- HCG level also must be measured.
The most specific criteria for diagnosing pelvic inflammatory disease include:
I. Endometrial biopsy with evidence of endometritis
II. Tranvaginal sonography or MRI showing thickened, fluid filled tubes with or without free pelvic fluid or tubo- ovarian complex.
III. Laparoscopic findings consistent with PID
It is important for patient to get early treatment as the pelvic inflammatory disease can cause few complication which can affect female fertility and sexual life such as ectopic pregnancy, infertility, and pelvic pain. Since there is lack of definitive diagnostic criteria for pelvic inflammatory disease, empirical treatment is recommended. Broad spectrum antibiotic given must cover Nesseria gonorrhoea, Chlamydia trachomatis, and a variety aerobic and anaerobic bacteria commonly found from genital tract in woman with PID. Treatment of PID can be classified into outpatient and inpatient treatment. The outpatient treatment is as effective as inpatient treatment for patient with clinically mild to moderate PID[7].
Outpatient Regimens
I. i.m. ceftriaxone 500mg single dose followed by oral doxycycline 100mg twice daily plus metronidazole 400mg twice daily for 14 days.
II. oral ofloxacin 400mg twice daily plus oral metronidazole 400mg twice daily for 14 days
Alternatives
I. Intramuscular ceftriaxone 500 mg immediately, followed by azithromycin 1 g/week for 2 weeks
II. oral moxifloxacin 400mg once daily for 14 days
Inpatient Regimens
I. i.v. ceftriaxone 2g daily plus i.v. doxycycline 100mg twice daily (oral doxycycline may be used if tolerated) followed by oral doxycycline 100mg twice daily plus oral metronidazole 400mg twice daily for a total of 14 days
II. i.v. clindamycin 900mg 3 times daily plus i.v. gentamicin (2mg/kg loading dose) followed by 1.5mg/kg 3 times daily [a single daily dose of 7mg/kg may be substituted]) followed by either oral clindamycin 450mg 4 times daily or oral doxycycline 100mg twice daily plusoral metronidazole 400mg twice daily to complete 14 days
Alternatives
I. i.v. ofloxacin 400mg BD plus i.v. metronidazole 500mg TID for 14 days
II. i.v. ciprofloxacin 200mg BD plus i.v. (or oral) doxycycline 100mg BD plus i.v. metronidazole 500mg TID for 14 days