Sexually Transmitted Infections: Case Study Number Three A twenty-one year presented with complaints of vague lower abdominal pain, vaginal discharge (non-odorous), for two days. She reported a similar episode eight months ago that she did not seek medical care.
Past medical History: Negative for any previous surgery or significant medical problems
GYN/OB History: G0P0AB0, LMP two days ago, regular menses without pattern or flow concerns. She is sexually active with one partner and had has two partners in the last year. She is not using any form of birth control at this time. The use of condoms to protect her from sexually transmitted diseases was not disclosed in this case.
Subjective Assessment:
GYN: Lower abdominal pain for two days …show more content…
Pelvic inflammatory disease (PID): This is the most likely differential based on her sexual history, presenting age, symptoms and physical findings. According to Ferri (2017), the presence of abdominal pain with "uterine tenderness, adnexal tenderness, and cervical motion tenderness" is highly suggestive of PID (p. 941). Differentials: a. Ectopic pregnancy: This should be ruled out based on her history of unprotected sex (Ferri, 2017). She did have a period two days ago, however this was the beginning of her pain as well. b. Tubo-ovarian abscess: This differential should be considered based on her chief complaint of abdominal pain (Ferri, 2017). Moreover, she described similar symptoms eight months ago that was untreated. Chlamydia infection can lead to this complication and should be considered (Park et al., 2017). When there is a presence of abdominal pain and high risk for STI, this differential should be included in the workup (Park et al., 2017). c. Urinary tract infection: This differential should be considered a source of infections due to the presence of lower abdominal pain and low grade fever (Ferri, 2017).
Past medical History: Negative for any previous surgery or significant medical problems
GYN/OB History: G0P0AB0, LMP two days ago, regular menses without pattern or flow concerns. She is sexually active with one partner and had has two partners in the last year. She is not using any form of birth control at this time. The use of condoms to protect her from sexually transmitted diseases was not disclosed in this case.
Subjective Assessment:
GYN: Lower abdominal pain for two days …show more content…
Pelvic inflammatory disease (PID): This is the most likely differential based on her sexual history, presenting age, symptoms and physical findings. According to Ferri (2017), the presence of abdominal pain with "uterine tenderness, adnexal tenderness, and cervical motion tenderness" is highly suggestive of PID (p. 941). Differentials: a. Ectopic pregnancy: This should be ruled out based on her history of unprotected sex (Ferri, 2017). She did have a period two days ago, however this was the beginning of her pain as well. b. Tubo-ovarian abscess: This differential should be considered based on her chief complaint of abdominal pain (Ferri, 2017). Moreover, she described similar symptoms eight months ago that was untreated. Chlamydia infection can lead to this complication and should be considered (Park et al., 2017). When there is a presence of abdominal pain and high risk for STI, this differential should be included in the workup (Park et al., 2017). c. Urinary tract infection: This differential should be considered a source of infections due to the presence of lower abdominal pain and low grade fever (Ferri, 2017).