Discussion #1

Discussion #1

 

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While interviewing this patient, we must ask many questions in order to fully evaluate and assess her symptoms in order to proceed with the appropriate action. The patient Kayla comes in today with pain in her lower left abdomen, near her pelvic area. We must get a comprehensive history and physical, as well as sexual history on Kayla as she is experiencing severe pain in her abdomen. We must ask Kayla:

· Where exactly is the pain located?

· How long have you been experiencing this pain?

· Does it get better or worse with certain movements or other interventions?

· Have you taken any medication for the pain and has it helped your symptoms?

· Are you sexually active?

· Do you and your partner use any method of birth control?

· Is there a chance you could be pregnant?

· Have you been tested for STD/STIs?

· What does your gynecological history consist of?

· Have you ever had symptoms like this before?

· Are you having any vaginal discharge?

Clinical findings that may be present in a patient with this condition would be sudden and intensely severe pain, in addition to nausea and vomiting. Usually in a patient with this condition, the patient experiences cramps for several days up to weeks leading up to the intense sharp pains. Ovarian torsion can also cause peritonitis within the abdominal cavity, causing more overlying abdominal discomfort and pains. Ovarian torsion is considered a medical emergency. If no action is taken, the ovary can lose blood supply and become necrotic, greatly impacting fertility and potentially rendering the ovary non-salvageable.

Diagnostic studies for  ovarian torsion typically involves the provider gathering information based upon the patient’s symptoms as well as physical exam. A physical exam would display the patient having severe pelvic pain, typically unilateral in nature. The affected side is typically palpable during an abdominal examination. At this point, an ultrasound is another diagnostic tool that is used to diagnose ovarian torsion. In this diagnostic test, a probe is inserted into the vagina which transmits sound waves to create images of internal structures such as the cervix, uterus, ovaries, tubes, and pelvic area. If ovarian torsion is confirmed with this examination, the patient must have laparoscopic surgery to untwist the ovary (Hawkins, J., Roberto-Nicholas,D. & Stanley-Haney, J. (2016).

The primary diagnosis for this patient is ovarian torsion. We know a woman who is experiencing severe, sudden, and intense pain in her pelvic area is presenting with all of the symptoms of ovarian torsion. Additionally, this diagnosis is especially appropriate when the patient is experiencing nausea and vomiting. This patient is also of reproductive age, which makes this a common diagnosis.

A differential diagnosis for this patient would be pelvic inflammatory disease, which was actually this patient’s initial diagnosis. Pelvic inflammatory disease is caused by an infection of the female reproductive system. Usually this condition occurs when a patient has had a history of STDs that may not have been treated. Women who are sexually active and are under the age of 25 are also at greater risk for PID. Douching and having an IUD place you at greater risk of developing PID as well (Schuiling, K. D. & Likis, F. E. (2016).

Another differential diagnosis for this patient would be a ruptured ovarian cyst. A ruptured ovarian cyst presents many similar symptoms to ovarian torsion. An ovarian cyst is a fluid filled sac on the ovary. These cysts can cause pelvic cramping every so often, causing a patient pain and discomfort. When one of these cysts ruptures, the patient will experience severe pain in the lower abdomen, and may even have internal bleeding. If severe, the patient may need to go to the hospital for IV fluids, pain management, and in rare cases, surgical intervention may be necessary.

The last differential diagnosis for this patient would be an ectopic pregnancy. We know this patient is sexually active, so an ectopic pregnancy could be a possibility. When a woman is experiencing an ectopic pregnancy, she will have sharp pain and abdominal cramps as well as nausea and vomiting. An ectopic pregnancy can be extremely dangerous as it could cause the fallopian tube to rupture or burst.

Management for this patient post surgically will involve her plan for recovery after her surgery and management of pain. She may need ibuprofen scheduled for pain management over the next following weeks. Her CBC, CMP, and urinalysis should be checked over the next following weeks to ensure she does not develop an infection, and that her blood levels remain adequate. She will require a great deal of education regarding her fertility status in the future, birth control methods available to her, and risk factors for developing pelvic infections since she just had surgery. The patient should know that she can still get pregnant even though she now only has one ovary. I would likely not recommend this patient utilize IUDs as a method of birth control given that she is placed at greater risk for pelvic infections now, and that she is only 16 and this will not protect her from STDs.

 

Discussion #2

 

For a patient who presents with probable PID, there are several questions that should be asked of the patient. First I would begin by asking about her symptoms and when they began. Is she experiencing pain? If so, where is the pain located, how would she describe it, and what has she tried for pain relief since the symptoms began. I would ask about age of onset of menses, how her cycles typically are such as length, symptoms, flow, etc. Because one of the characteristic symptoms of PID is abrupt onset of lower abdominal pain immediately following menses, I would ask about her most recent cycle. Has the patient experienced any other symptoms such as nausea, vomiting, fever, back ache, burning or burning on urination, bleeding, vaginal discharge, odor or itching. I would also question whether the pain is exacerbated by movement Valsalva, palpation or sex. It is important to know if the patient is sexually active, uses condoms if so, and any history of STIs. Has the patient had any significant gynecological history such as ovarian cysts that could also be a source of her acute pain? A patient with PID will typically present with an acute lower abdominal pain, usually bilaterally, that began immediately after menses. The pain can be described anywhere from intense, throbbing or radiating to even mild for some patients. Many patients will also report symptoms such as irregular vaginal discharge, spotting between menses, nausea, vomiting, fever, pelvic and low back pain (Schooling & Likis, 2017).

Diagnosing PID should include drawing labs such as CBC, CMP, ESR, C reactive protein, and full STD panel. The patient should also have bacterial swabs sent for review, a urinalysis and culture. Vaginal fluid may show an increased number of white blood cells on saline microscopy. I would also want an abdominal ultrasound to rule out any other differential diagnoses such as ovarian cysts, ovarian torsion, ectopic pregnancy, endometriosis, IBD and appendicitis. Endometrial biopsy with histopatholigical evidence of endometriosis, transvaginal ultrasound, MRI and laproscopy are the other diagnostic tests that can diagnose PID (Schooling & Likis, 2017).

In the case of this patient, the primary diagnosis was PID, however the differentials should have included ovarian cyst with torsion, ectopic pregnancy and endometriosis. It would also be imperative to rule out appendicitis with the acute onset and location of her pain. All of these include acute abdominal pain in the lower quadrants and should be evaluated in the female patient. Because the patient is sexually active, it is important to rule out ectopic pregnancy. Although the patient has not had a history of ovarian cysts, because of the detrimental outcome of an untreated cyst with torsion, it is also extremely important to rule this out as well before coming to a conclusion of PID (Schooling & Likis, 2017).

 

Treatment of PID includes oral antibiotics if the patient can tolerate or is safe for home treatment, or inpatient treatment with IV antibiotics. The gold standard treatment for PID is Ceftriaxone 250mg IM one time plus doxycycline 100mg orally 2 times a day for 14 days with or without flagyl 500mg orally 2 times a day for 14 days. The patient with this regimen should be educated on the importance of finishing the whole treatment and not drinking while on flagyl.  The patient should abstain from sexual intercourse until treatment is completed, symptoms are resolved and the partner has been adequately treated as well. Male partners within the last 60 days should be treated (Schooling & Likis, 2017).

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