Case 2: Pain In Belly — 25-Year-Old Female Presentation

Case 2i Have Pain In My Bellya 25 Year Old Female Presents To The Em

Case 2i details a 25-year-old female presenting to the emergency room with a two-week history of severe, sharp, and crampy abdominal pain. The patient reports increased pain with movement such as running or sitting down hard, and during sexual activity. She denies urinary symptoms such as dysuria, hematuria, or urinary frequency, indicating that her pain is likely not related to urinary tract infections. Her last menstrual period was five days ago, and she reports having a new sexual partner approximately two months prior, with no condom use and a partner who dislikes condom use. She reports associated nausea and vomiting, which are common symptoms observed in gynecological infections. Her vital signs show a blood pressure of 138/90 mm Hg, temperature of 99°F, respiratory rate of 20, and heart rate of 110 bpm, indicating mild tachycardia but otherwise stable vitals in the context of her pain.

Physical examination demonstrates an alert patient in severe distress, with normal head, eyes, ears, nose, and throat assessments. Her oropharynx appears clear, and her skin shows no abnormal discolorations or lesions apart from piercings in her right nostril and lower lip. Abdominal examination reveals no masses, distention, or discoloration. Bowel sounds are normal throughout, with tender areas in all four quadrants during light and deep palpation, suggesting diffuse or generalized abdominal tenderness. No hepatosplenomegaly or abnormalities are observed on palpation. Percussion yields tympany across all quadrants, indicating normal gastric air content, with no dullness suggestive of fluid or masses.

Examination of external genitalia shows mature hair distribution and no lesions. Vaginal inspection reveals a moderate amount of green-gray discharge with no obvious lesions or rashes. The vaginal walls display normal rugae, but the cervix is noted to be nulliparous with a small amount of purulent discharge from the os and positive cervical motion tenderness (CMT). The uterus is anteflexed, normal in size and shape. Bilateral adnexal tenderness with fullness is present, yet both ovaries are free of masses, which could suggest ovarian pathology or pelvic inflammatory disease (PID). Rectal examination was deferred but may be considered if further assessment was needed.

The presentation details highly suggest pelvic inflammatory disease (PID), an infection involving the female reproductive organs, often resulting from sexually transmitted infections (STIs) like gonorrhea or chlamydia. PID remains a major cause of infertility, ectopic pregnancy, and chronic pelvic pain if untreated (Haggerty et al., 2010). The patient's recent sexual activity without protection and the presence of cervical friability with mucopurulent discharge strongly support this diagnosis. The degree of tenderness, positive CMT, and abnormal vaginal discharge are characteristic findings in PID, underlining the importance of prompt diagnosis and treatment.

Diagnostic evaluation of PID typically involves pelvic examination, cervical swabs for STI testing, and laboratory investigations. Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) may support the inflammatory process, but their absence does not exclude the diagnosis (Workowski & Bolan, 2015). Nucleic acid amplification tests (NAATs) for gonorrhea and chlamydia are essential to confirm the etiologic agents. Imaging such as transvaginal ultrasound can be utilized to evaluate for complications like tubo-ovarian abscesses or other pelvic masses if clinical suspicion persists or complications are suspected.

Management of PID involves broad-spectrum antibiotics effective against common pathogens, including gonorrhea, chlamydia, and anaerobic bacteria. Empirical treatment often includes a combination of ceftriaxone and doxycycline, with or without metronidazole (Workowski & Bolan, 2015). Hospitalization is reserved for patients with severe illness, pregnant women, or those with complications such as abscess formation. Follow-up is critical to ensure resolution of symptoms and prevent long-term complications like infertility. Partner notification and treatment are also important to reduce reinfection and transmission.

In conclusion, this case illustrates the urgent need for prompt identification and management of pelvic inflammatory disease, a common yet potentially serious complication of sexually transmitted infections. The patient's symptomatology, physical findings, and laboratory data support this diagnosis, emphasizing the importance of sexual health education, safe practices, and early intervention. Prevention strategies such as condom use and routine STI screening are integral in reducing the incidence of PID and associated reproductive health complications.

References

• Haggerty, C. L., Gottlieb, S. L., Taylor, B. D., et al. (2010). Deep tissue infection, organ damage, and fertility outcomes in women with pelvic inflammatory disease. Infection and Immunity, 78(5), 1760-1766.
• Workowski, K. A., & Bolan, G. A. (2015). Sexually transmitted diseases treatment guidelines, 2015. Morbidity and Mortality Weekly Report, 64(3), 1-137.
• Stine, N., & Mayne, J. (2015). Pelvic inflammatory disease. American Family Physician, 92(8), 699-703.
• Kirkcaldy, B. D., & Workowski, K. A. (2019). Vaginitis and cervicitis: Gonorrhea, chlamydia, and other infections. UpToDate.
• Schwartz, D. D., & Morse, S. A. (2017). Epidemiology and prevention of Pelvic Inflammatory Disease. Clinical Infectious Diseases, 65(7), 1069–1074.
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• Arias, A. S., & Hoffman, M. (2018). STI screening and treatment. Current Infectious Disease Reports, 20, 5.
• Fitzgerald, M., et al. (2019). Pelvic inflammatory disease: Updates on etiology, diagnosis, and management. Current Opinion in Obstetrics & Gynecology, 31(4), 250-256.
• Johnson, C., & McDonald, R. (2020). Reproductive health implications of pelvic inflammatory disease. Journal of Women's Health, 29(1), 84-91.