Question

Cathy, a 20-year-old college sophomore, visits the student health center complaining of nausea, vomiting, and extreme abdominal pain. She says the pain came on suddenly after a meal, so she is concerned about food poisoning. During the patient history, Cathy discloses that she is sexually active and has more than 10 sexual partners per year. She uses oral contraceptives as her primary method of birth control and does not rely on her partners to use condoms. Cathy has a past history of vulvovaginitis, cervicitis, and numerous STDs (chlamydia, syphilis, and genital herpes). Recently she has noticed a whitish vulva discharge with a strong odor that has increased in quantity over the past week. Cathy’s vital signs are as follows:

      Oral temperature = 101.4ºF (38.6ºC)

Heart rate = 78 beats/min

      Respiratory rate = 15 breaths/min

      Blood pressure = 150/86 mmHg

      A gynecological examination is performed. Palpation of the abdomen reveals abdominal guarding, rebound tenderness, and an enlarged, painful uterus. A surgical scar is also noted, and Cathy explains that her appendix was removed when she was a child. The external genitalia appear slightly edematous but are otherwise normal. Both the vulva and the cervix are slightly inflamed, and a purulent discharge is noted. A sample of the discharge is taken for culture, and a cell sample is taken from the external os for a Pap smear. During the pelvic examination, movement of the cervix creates abdominal discomfort, and the rectovaginal examination confirms the uterine enlargement noted upon palpation.

      Blood, fecal, and urethral samples are obtained. Blood tests reveal leukocytosis but no HIV antibodies. The Pap smear is negative, and the cultures are positive for Chlamydia and Neisseria gonorrhoeae. A pregnancy test (HCG assay) is negative. Ultrasound imaging of the pelvic cavity shows enlargement of the uterus and uterine tubes without pregnancy. Based on these test results, Cathy is diagnosed with pelvic inflammatory disease.

      Cathy is prescribed a combination of antibiotics and bed rest for 10 days. During this treatment period, she is told to refrain from intercourse. She is also advised to notify her partners about her condition and to encourage them to seek treatment. In addition, Cathy is told to return for a follow-up examination after completing her medication to ensure that the infections have been controlled. Finally, Cathy is encouraged to insist on condom use to minimize her chances of contracting STDs in the future. Because of her history of numerous STDs, she is warned that she is at increased risk for infertility due to uterine tube scarring as well as for uterine and cervical cancer.

1.Which of Cathy’s signs and symptoms are common to both pelvic inflammatory disease and appendicitis? Why is it important to rule out appendicitis?

2. What signs and symptoms support the diagnosis of PID?
3. Suppose Cathy says that in spite of her “wildness” in college, she just wants to “get it all out of my system, and then settle down and have kids after I graduate.” As her physician, what would you tell her about the relevance of her present behavior to her family plans?
4. Why are a Pap smear and an HIV test conducted?
5. Why do Cathy’s signs and symptoms rule out cervical, endometrial, and ovarian cancer?

Answer 1

1. Signs and symptoms common to Appendicitis and Pelvic inflammatory disease (PID):

Fever, Nausea, Vomiting, Extreme abdominal pain, Rebound tenderness,Abdominal guarding and rigidity

Cathy have all the above symptoms so essential to rule out Acute appendicitis.

2. Signs and symptoms in favour of PID :

edematous external genitalia is a sign of wild sexual relation ship with multiple sexual partners and PID.

vulva and the cervix are slightly inflamed, and a purulent discharge is noted - sign of PID

During the pelvic examination, movement of the cervix creates abdominal discomfort - sign of PID

rectovaginal examination confirms the uterine enlargement noted upon palpation - sign of PID

Fever, Nausea, Vomiting, Extreme abdominal pain, Rebound tenderness,Abdominal guarding and rigidity - signs favour of PID

3. As a Physician, Advise to her for family life

She should stop her wild sexual activity with multiple boy friends and change her behaviour to one woman for one man like traditional indian system of male - female relation ship. She should maintain the hygeine of genital organs always. She should take the current advised antibiotics for PID at prescribed duration

4.Pap smear for rule out cervical malignancy which is common in ladies who has wild sexual activity like cathy

5. HIV test for rule out AIDS & HIV infection Which is sexually transmitted most commonly

She use oral contraceptives as primary method of contraceptive which make her more chance to get malignancy of female reproductive tract, so its need to rule out.