next step?
a. Laparoscopy
b. High vaginal swab
c. Hysteroscopy
d. Laparotomy
e. US
answer: B
discharge and the symptoms given point to PID, laporoscopy is the GOLD standard but next step would be a swab for c+s which will help us choose the best AB regimen
PID
Clinical
Presentation
• up to 2/3 asymptomatic: many subtle or mild symptoms
• common
·
fever >38.3ºC
·
lower abdominal pain and tenderness
·
abnormal discharge: cervical or vaginal
•
uncommon
·
N/V
·
dysuria
·
AUB
• chronic
disease (often due to chlamydia)
·
constant pelvic pain
·
dyspareunia
·
palpable mass
·
very difficult to treat, may require surgery
Investigations
• blood work
·
β-hCG (must rule out ectopic pregnancy),
CBC, blood cultures if suspect septicemia
• urine R&M
• speculum exam, bimanual exam
·
vaginal swab for Gram stain, C&S
·
cervical cultures for N. gonorrhoeae, C.
trachomatis
·
endometrial biopsy will give definitive
diagnosis (rarely done)
• ultrasound
·
may be normal
·
free fluid in cul-de-sac
·
pelvic or tubo-ovarian abscess
·
hydrosalpinx (dilated fallopian tube)
• laparoscopy (gold standard)
·
for definitive diagnosis: may miss
subtle inflammation of tubes or endometritis
Treat PID with FOXY DOXY
(cefoxitin + doxycycline)
If
the risk of gonococcal infection is low,
prescribe any of the following:
·
Oral levofloxacin/ofloxacin
400 mg twice daily plus oral metronidazole 400 mg twice daily,
both for 14 days.
·
Ceftriaxone 500 mg as a single IM dose, followed by oral doxycycline 100 mg
twice daily plus oral metronidazole 400 mg twice
daily, both for 14 days.
·
Ceftriaxone 500 mg as a single IM dose, followed
by oral azithromycin 1 g per week for 2 weeks. Not recommended.
If
the risk of gonococcal infection is high
(for example the woman's partner has gonorrhoea, her symptoms and signs are
clinically severe, or she has had sexual contact whilst abroad), prescribe
either of the following:
·
Ceftriaxone 500 mg as a single IM dose, followed by oral doxycycline 100 mg
twice daily plus oral metronidazole 400 mg twice
daily, both for 14 days
N.B.
A regimen of metronidazole and doxycycline without
intramuscular ceftriaxone is not recommended.
Oral cefixime 400 mg as a single dose (off-label use) can
be used as an alternative to ceftriaxone 500 mg in the above regimens.
Regimens containing ofloxacin or azithromycin are not
recommended in women at high risk of gonococcal PID.
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