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Clinical Assessment: 28-Year-Old Female

Presentation Summary

• Infra-umbilical (lower) abdominal pain - 2 months
• Nausea
• Whitish vaginal discharge - 2 months

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Most Likely Diagnosis: Pelvic Inflammatory Disease (PID)

• Young sexually active woman
• Bilateral lower/infra-umbilical pelvic pain (2 months - suggests subacute/chronic or recurrent)
• Vaginal discharge
• Nausea (a recognized symptom)

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Microbiology

• Neisseria gonorrhoeae
• Chlamydia trachomatis
• Mycoplasma genitalium
• Anaerobes (BV-associated: Prevotella spp., peptostreptococci, E. coli, H. influenzae, group B streptococci)

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Clinical Features to Elicit on Examination

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Investigations

• Urine pregnancy test (must rule out ectopic pregnancy)
• High vaginal swab / endocervical swab: NAAT for N. gonorrhoeae and C. trachomatis
• Wet mount of vaginal secretions: look for PMNs outnumbering epithelial cells
• CBC (leukocytosis), ESR, CRP
• Urine routine/microscopy (rule out UTI)

• Pelvic/transvaginal ultrasound - first-line imaging; can show tubal hyperemia, thickened fluid-filled tubes, free fluid, or frank TOA
• MRI pelvis if ultrasound is inconclusive
• CT abdomen if perihepatitis/generalized peritonitis suspected (Fitz-Hugh-Curtis syndrome)

• Endometritis on endometrial biopsy
• Thickened, fluid-filled fallopian tubes on ultrasound or MRI
• Laparoscopic evidence (tubal edema, erythema, purulent discharge) - reserved for diagnostic uncertainty

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Differential Diagnosis

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Treatment

Indications for Inpatient Treatment:

• Pregnancy
• Cannot exclude appendicitis or ectopic pregnancy
• Severe nausea/vomiting precluding oral antibiotics
• Disseminated gonorrhea, peritonitis, perihepatitis
• Systemic sepsis
• Tubo-ovarian abscess

Outpatient (Oral) Regimen (CDC / Harrison's 22e, 2025):

• Ceftriaxone 500 mg IM single dose
• + Doxycycline 100 mg PO twice daily x 14 days
• + Metronidazole 500 mg PO twice daily x 14 days

• Levofloxacin 500 mg PO once daily x 14 days (if cephalosporin allergy and gonorrhea ruled out)

Inpatient (Parenteral) Regimen:

• Cefotetan 2g IV q12h OR Cefoxitin 2g IV q6h + Doxycycline 100 mg IV/PO q12h

• Clindamycin 900 mg IV q8h + Gentamicin (loading dose 2 mg/kg IV, then 1.5 mg/kg q8h)

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Complications if Untreated

• Tubo-ovarian abscess (TOA) - bilateral, life-threatening if ruptured (gram-negative endotoxic shock)
• Fitz-Hugh-Curtis syndrome - perihepatitis (RUQ pain mimicking cholecystitis/hepatitis)
• Infertility - tubal factor (each episode of PID increases risk)
• Ectopic pregnancy - tubal scarring
• Chronic pelvic pain

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Additional Points

• Always test for and treat the partner for STIs (contact tracing)
• Counsel on safe sex/barrier contraception
• Re-evaluate at 72 hours - if no improvement, reconsider diagnosis or need for hospitalization/laparoscopy
• If pregnancy test is positive: suspect ectopic pregnancy or infected IUP - surgical consultation urgently

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• Harrison's Principles of Internal Medicine, 22e (2025) - Goldman-Cecil Medicine, International Edition - Berek & Novak's Gynecology

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OPD CASE PAPER

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PATIENT DETAILS

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CHIEF COMPLAINTS

1. Pain in abdomen - infra-umbilical region - since 2 months
2. Nausea - since 2 months
3. Whitish vaginal discharge (leucorrhoea) - since 2 months

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HISTORY OF PRESENT ILLNESS (HOPI)

• No history of fever (to be confirmed)
• No history of dysuria or increased urinary frequency
• No history of dyspareunia (painful intercourse)
• No history of abnormal uterine bleeding / menorrhagia / metrorrhagia
• No history of diarrhea or constipation
• No history of weight loss
• No history of previous similar episodes
• No history of any recent intrauterine procedure (IUCD insertion, D&C, MTP)

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MENSTRUAL HISTORY

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OBSTETRIC HISTORY

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PAST HISTORY

• No history of previous similar illness
• No history of previous surgeries
• No known comorbidities (Diabetes, Hypertension, Tuberculosis)
• No known drug allergies

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PERSONAL HISTORY

• Diet: Vegetarian / Mixed
• Appetite: Normal / Decreased
• Bowel and bladder habits: Regular
• Sleep: Normal / Disturbed
• Addiction: Nil

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SEXUAL HISTORY (important - must be taken sensitively)

• Sexually active: Yes / No
• Number of partners: (to note)
• Partner's symptoms (urethral discharge, dysuria): (to note)
• History of prior STI: (to note)
• Use of barrier contraception: Yes / No

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FAMILY HISTORY

• Not significant

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GENERAL PHYSICAL EXAMINATION (GPE)

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SYSTEMIC EXAMINATION

Cardiovascular System

• S1, S2 heard, no murmurs

Respiratory System

• Bilateral air entry equal, no added sounds

Central Nervous System

• No focal neurological deficit

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ABDOMINAL EXAMINATION

• Abdomen flat / mildly distended
• No visible peristalsis
• No visible mass
• No engorged veins

• Abdomen soft / guarded
• Tenderness present in infra-umbilical (hypogastric) region bilaterally
• No rebound tenderness (to check)
• No palpable mass
• Liver and spleen not palpable
• Kidneys not palpable
• No CVAT (costovertebral angle tenderness)

• Tympanic in most areas
• No shifting dullness

• Bowel sounds present, normal

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GYNAECOLOGICAL EXAMINATION

External Genitalia

• No ulcers, no warts, no skin lesions

Speculum Examination (Per Speculum - P/S)

• Cervix: (note appearance - healthy / congested / ectropion)
• Cervical os: Closed
• Cervical discharge: Whitish / Mucopurulent discharge coming from os (key finding)
• Vaginal walls: No lesions

Bimanual Examination (Per Vaginum - P/V)

• Uterus: Anteverted / Retroverted, normal size, mobile
• Cervical Motion Tenderness (CMT): PRESENT (hallmark sign of PID)
• Uterine fundal tenderness: Present / Absent
• Adnexa (bilateral): Tenderness present bilaterally / No adnexal mass felt
• (If adnexal mass felt - suspect Tubo-Ovarian Abscess)

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PROVISIONAL DIAGNOSIS

• Likely subacute / chronic PID given 2-month duration
• Most probable organisms: Chlamydia trachomatis, Neisseria gonorrhoeae, anaerobes

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DIFFERENTIAL DIAGNOSIS

1. Ectopic Pregnancy - ruled out by negative pregnancy test; possible if LMP missed
2. Appendicitis - usually right-sided, acute, no vaginal discharge
3. Ovarian Cyst (torsion / rupture) - usually acute, unilateral, adnexal mass on USG
4. Tubo-Ovarian Abscess (TOA) - complication of PID; palpable mass, high fever
5. Endometriosis - cyclic pain, dysmenorrhea, no discharge/fever
6. Bacterial Vaginosis / Vaginitis - no upper tract signs, no CMT
7. Urinary Tract Infection - dysuria, frequency, positive urine culture
8. Fibroid Uterus - heavy bleeding, enlarged uterus on examination

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INVESTIGATIONS

A. MANDATORY (First Line - Order immediately)

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1. Urine Pregnancy Test (UPT) / Serum Beta-hCG

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2. Complete Blood Count (CBC)

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3. C-Reactive Protein (CRP)

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4. High Vaginal Swab (HVS) + Endocervical Swab

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5. Pelvic Ultrasound (Transvaginal preferred / Transabdominal)

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6. Urine Routine & Microscopy + Culture/Sensitivity

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7. Random Blood Sugar (RBS)

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B. SECONDARY INVESTIGATIONS (Based on findings)

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8. MRI Pelvis

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9. CT Abdomen and Pelvis

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10. Liver Function Tests (LFT)

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11. Endometrial Biopsy

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12. Laparoscopy (Diagnostic)

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PRESCRIPTION

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Rx

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ANTIBIOTIC REGIMEN (CDC / Harrison's 22e Guidelines - 14 days)

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• Class: 3rd generation cephalosporin
• Why: Covers Neisseria gonorrhoeae (single IM dose is sufficient). Gonorrhea is a primary cause of PID and must be covered even if not yet confirmed on culture.
• Dose: 500 mg intramuscular, single dose, given in OPD itself
• Note: Administer with lignocaine 1% (1 mL) to reduce injection pain

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• Class: Tetracycline antibiotic
• Why: Gold-standard cover for Chlamydia trachomatis and Mycoplasma genitalium - the commonest causes of subacute/chronic PID. Excellent intracellular penetration.
• Dose: 100 mg orally, twice daily (morning and night), after food
• Duration: 14 days (do not stop early even if symptoms improve)
• Precaution: Take with full glass of water, do not lie down for 30 minutes after taking (prevents oesophageal ulceration). Avoid sun exposure (photosensitivity). Contraindicated in pregnancy.

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• Class: Nitroimidazole antibiotic
• Why: Covers anaerobic bacteria (Prevotella, peptostreptococci, Bacteroides) which are always co-present in PID. Also covers Trichomonas vaginalis and Bacterial Vaginosis organisms. Adding metronidazole significantly reduces endometrial anaerobes and pelvic tenderness.
• Dose: 400 mg orally, twice daily, after food
• Duration: 14 days
• Precaution: Avoid alcohol completely during treatment and 48 hours after (severe disulfiram-like reaction). May cause metallic taste in mouth - expected side effect.

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SYMPTOMATIC RELIEF

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• Why: For pain relief (pelvic pain) and mild fever. NSAIDs also reduce peritoneal inflammation.
• Dose: 1 tablet three times daily, after food
• Duration: 5 days or until pain subsides
• Precaution: Take strictly after food. Avoid if gastric ulcer history.

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• Why: For nausea (a prominent symptom in this patient). Serotonin 5-HT3 antagonist.
• Dose: 4 mg orally, twice daily, 30 minutes before meals
• Duration: 5 days or as needed
• Alternative: Tab. Domperidone 10 mg TDS before meals

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• Why: Broad-spectrum antibiotic use (especially doxycycline + metronidazole) disrupts normal vaginal and gut flora. Probiotics restore Lactobacillus-dominant vaginal microbiome and prevent antibiotic-associated diarrhoea and candidal superinfection.
• Dose: 1 capsule twice daily, with meals

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• Why: If hemoglobin is borderline low (common in young women with chronic infection/inflammation). Nutritional supplementation.
• Dose: 1 tablet daily after dinner

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ADVICE AND COUNSELLING

1. Complete the full 14-day antibiotic course - even if symptoms improve earlier. Stopping early causes treatment failure and antibiotic resistance.
2. Partner treatment is mandatory - Sexual partner(s) must be tested and treated for STIs (gonorrhoea, chlamydia) simultaneously. Reinfection from an untreated partner is a major cause of recurrent PID.
3. Abstain from sexual intercourse until both patient and partner complete full treatment and are symptom-free.
4. Use barrier contraception (condoms) after completing treatment to prevent reinfection.
5. Avoid vaginal douching - disrupts natural protective vaginal flora, increases PID risk.
6. Return immediately if:
   • Fever >38.3°C develops
   • Vomiting prevents taking oral medications
   • Worsening or new severe abdominal pain
   • Pregnancy test turns positive
   • No improvement within 72 hours of starting treatment
7. Follow-up in 72 hours - mandatory review to assess treatment response. If no improvement, consider inpatient admission and parenteral antibiotics.
8. Follow-up at 2 weeks - to review investigations, check swab results, confirm cure.

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FOLLOW-UP SCHEDULE

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INDICATIONS FOR IMMEDIATE HOSPITAL ADMISSION

• Inability to tolerate oral medications (severe vomiting)
• Pregnancy (PID in pregnancy requires inpatient IV antibiotics)
• Suspected / confirmed Tubo-Ovarian Abscess on USG
• Signs of systemic sepsis (high fever, tachycardia, hypotension)
• Peritonitis (diffuse guarding, rigidity)
• No clinical improvement after 72 hours of outpatient treatment
• Diagnostic uncertainty (cannot rule out appendicitis, ectopic pregnancy)

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INPATIENT REGIMEN (if admission required)

• Inj. Cefotetan 2g IV every 12 hours OR Inj. Cefoxitin 2g IV every 6 hours
• + Inj./Tab. Doxycycline 100 mg every 12 hours

• Inj. Clindamycin 900 mg IV every 8 hours
• + Inj. Gentamicin IV (loading dose 2 mg/kg, then 1.5 mg/kg every 8 hours)

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DOCTOR'S SIGNATURE

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