1. Block I

2. History

3. General Data  JM  18/F  Single, college student, RC, from Taguig  CC: hypogastric pain  First consult at OBAS last January 12, 2010

4. Present Illness  5 weeks PTC – onset of hypo-gastric pain during her menses, persisting after her menstrual period  Consulted a private MD  dysmenorrhea

5. Present Illness  3 weeks PTC – persistence of hypogastric pain with occasional vaginal spotting, (+) yellowish foul smelling discharge, high grade fever Tmax 38.5 0 C  Consult at PGH OPD  Pap smear done, advised TV-UTZ on follow-up, prescribed Metronidazole 500mg TID x 7 days

6. Present Illness  On follow-up, TV-UTZ reading showed:  Uterus is anteverted with smooth with homogenous echopattern measuring 7 x 4 x 3.2 cm, cervix is 3.4 x 2.4 x 2.0 cm, endometrium is hyperechoic measuring 0.8 cm, thick with intact subendometrial halo. The right ovary measures 3 x 1.8 x 2.0 cm. The left ovary is converted into a locular anechoic cyst measuring 5.8 x 4.1 x 4.7 cm, densely adherent and medial to it is a complex tubule cystic structure measuring 8.7 x 6.4 x 5 cm with low to mid level fluid and incomplete septation within. It is densely adherent to the wall, Cul de sac and pelvic structure. There is no free fluid in the cul de sac.

7. Present Illness  Assessment at OPD: Tubo-ovarian abscess, Left  Patient was advised to consult at OBAS for admission

8. ROS  no pruritus, dysuria, or changes in bowel movement

9. Past Medical History  non-asthmatic, non-diabetic and non- hypertensive  no previous hospitalizations or surgeries  no known allergies

10. Family Medical History  HPN - mother

11. Personal-Social History  second year college student, taking up HRM  occasional alcoholic beverage drinker and smoker  first sexual contact at 17  2 promiscuous sexual partners

12. Gynecologic History  denies use of intrauterine devices, oral contraceptive pills and other forms of contraceptives  Menarche at 13  Regular monthly intervals, lasting 5 days, 2-3 pads per day  (+) dysmenorrhea  LNMP: Jan 11, 2010 PMP: Dec 2009  nulligravid

13. P.E.  BP 100/60, HR 92, RR 20, Temp 37.7 0 C  Unremarkable systemic findings  Abdomen: flat and soft, normoactive bowel sounds, (+) hypogastric tenderness, (-) masses

14. P.E.  IE: normal external genitalia, nulliparous vagina, smooth and closed cervix, (+) wriggling tenderness, uterus is small, (-) right adnexal mass, (+) left adnexal mass measuring 6 x 6 cm, cystic, movable, and tender  DRE: good sphincter tone, intact rectal vault, inferior pole of the mass is not palpable in the cul de sac, (+) stool per examining finger, (-) blood

15. Assessment  Tubo-ovarian complex, left  Patient was subsequently admitted

16. Management  Started on 900 mg IV q8, Amikacin 750 mg IV OD, and Ampicillin 1g IV q6  Plan: IV antibiotics for 3 days then repeat UTZ for possible laparoscopy  Day 3: seen by OB-IDS  HBs Ag, RPR, and ICC-ELISA ordered  Antibiotics continued

17. Management  Day 7  OB-IDS opinion: medical management and IV laparoscopic aspiration alone may not be adequate due to size of mass  Suggest exploratory laparoscopy and conservative surgery

18. Management  Day 10  Patient underwent exploratory laparoscopy, salphingectomy and oophorocystectomy, left  She was subsequently discharged improved and advised regular follow-up at the PGH- OPD

19. Lab Exams and Results Urinalysis CharacteristicsYellow,hazy Specific gravity1.03 SugarNeg ProteinTrace RBC7-12 WBC0-3 Epith cells1+ BacteriaOccasional Mucus thread2+ Cast/crystalsneg

20. Lab Exams and Results CBC 1/121/22 HGB138104 HCT0.4350.327 WBC9.8215.40 NEU0.6600.880 LYMPH0.2460.06 PLT451387

21. Lab Exams and Results Blood Chemistry BUN1.23Mg0.90 CREA53K4.3 ALB53Cl100 Ca2.37

22. Lab Exams and Results Other Blood Tests ESR11 (N: 0-20) HBsAgNonreactive RPRNonreactive HIV Ag/AbNonreactive

23. Discussion

24. 1. Pertinent points in history  17/f  5-week history of hypogastric pain  With vaginal spotting, foul-smelling discharge, high-grade fever  2 promiscuous sexual partners  History of dysmenorrhea

25. 2. Differential Diagnosis  Appendicitis  most common cause of surgical abdomen in young adults  Ectopic pregnancy  Endometriosis  Ovarian Torsion  Acute diverticulitis

26. 3. Diagnostics Laboratory tests may include the following:  Urine pregnancy test  Urinalysis  Complete blood count  Cervical cultures for gonorrhea and chlamydia  Testing for other sexually transmitted diseases, including syphilis and HIV

27. 3. Diagnostics Direct visualization via the laparoscope – most accurate method of diagnosing acute PID Ultrasound – first diagnostic imaging examination to be performed in cases of suspected pelvic inflammatory disease (PID) Transvaginal sonography (TVS) – allows detailed visualization of the uterus and adnexa, including the ovaries – the fallopian tubes are usually imaged only when they are abnormal and distended on physical examination, primarily from postinflammatory obstruction

28.  Transabdominal sonography (TAS)  complementary to the endovaginal examination because it provides a more global view of the pelvic contents  Whether TAS (bladder filling required) or TVS (bladder filling not required) is performed first and whether the complementary examination is needed for a final diagnosis is a matter of individual clinical imaging practice.

29.  Magnetic resonance imaging (MRI)  serves as an excellent imaging modality in cases in which the ultrasonographic findings are equivocal  Computed tomography (CT) scanning  may be used as the initial diagnostic study for the investigation of nonspecific pelvic pain in a female

30. 4. Do you agree with the primary management?  Yes  Complicated PID generally warrants hospitalization due to the risk for sepsis  Broad-spectrum IV antibiotic coverage is requir  In cases refractory to medical therapy, surgery is the definitive treatment  Radical surgery was avoided since the abscess was unilateral

31. 5. Significant P.E. findings  Fever (37.7 degrees)  Hypogastric tenderness, wriggling tenderness, and left adnexal tenderness  left adnexal mass measuring 6 x 6 cm, cystic, movable, and tender

32. 6. Given the clinical picture and with the aid of diagnostic exams, what is the most probable diagnosis?  Tubo-ovarian abscess

33. 7. What is Pelvic Inflammatory Disease?  Most common serious complication of STIs  Also known as acute salpingitis  Increases risk for infertility and ectopic pregnancies  Usually seen in young women (15-19 years)

34. 7. What is Pelvic Inflammatory Disease?  Risk factors  Young age group  Non-white and non-Asian ethnicity  Being unmarried  Recent history of douching  Cigarette smoking  IUD use  Barrier contraceptives decrease risk

35. 7. What is Pelvic Inflammatory Disease?  Manifestations  Hypogastric, adnexal, and wriggling tenderness  +/- fever (seen in 20% of cases)  Vaginal discharge, abnormal odor, abnormal bleeding, GI disturbances, urinary tract symptoms

36. 7. What is Pelvic Inflammatory Disease?  Manifestations  Hypogastric, adnexal, and wriggling tenderness  +/- fever (seen in 20% of cases)  Vaginal discharge, abnormal odor, abnormal bleeding, GI disturbances, urinary tract symptoms

37. The Centers for Disease Control and Prevention (CDC) criteria for the diagnosis of PID are as follows: Minimum criteria (1 or more): – Lower abdominal tenderness – Adnexal tenderness – Tenderness with cervical motion Additional criteria: Patients with PID should have 1 or more of the following: – Signs of lower genital tract inflammation – Oral temperature higher than 101ºF – Abnormal cervical and vaginal discharge – Greatly increased numbers of white blood cells on saline microscopy of vaginal secretions – Elevated erythrocyte sedimentation rate – Elevated C-reactive protein level – Laboratory documentation of cervical infection with C trachomatis or N gonorrhoeae Elaborate criteria (additional findings include the following): – Histopathologic evidence of endometritis at endometrial biopsy – Thickened fluid-filled tubes with or without free pelvic fluid or a tubo-ovarian complex on transvaginal sonograms or images from other modalities – Laparoscopic abnormalities that are consistent with PID

38. 8. What are the risk factors of our patient?  Risk factors  Young age group  Non-white and non-Asian ethnicity  Being unmarried  Recent history of douching  Cigarette smoking  IUD use  No use of barrier contraceptives

39. 9. Hallmarks of management PID is commonly treated as an outpatient disease, with the use of oral antibiotics that cover both aerobic and anaerobic organisms, including C trachomatis and N gonorrhoeae. Treatment is usually started before the endocervical culture results are available (empiric therapy) because negative findings do not exclude a diagnosis of PID in the upper genital tract. Empiric treatment is recommended if the minimum criteria are fulfilled and if no other cause for the patient's symptoms is identified.

40. The CDC recommends hospitalization and administration of intravenous antibiotics in patients with the following: – uncertain diagnosis – pregnancy – failure to adhere to or respond to oral treatment – severe illness – TOA – immunodeficiency, – human immunodeficiency virus infection

41. 10. What is the prognosis and the possible sequelae of the disease?  Survival rates are high if managed properly  Infertility and ectopic pregnancies are common sequelae