2. Objectives:
1)To present an index patient admitted for abdominal
pain.
2)To discuss the family profile of X Family
3)To discuss the clinical manifestations, diagnosis &
management of PID
4)To establish family diagnosis, intervention &
recommendation using family assessment tools
3. The Case
GENERAL DATA
Pt. X, 21 yo, female, single, Call center agent
From Camotes, Cebu
temporarily residing in Mandaue City
Admitted for the first time due to abdominal pain
4. Past Medical Hx:
No known medical problem
Smoker for 6 years (20 sticks/day)
An alcoholic beverage drinker (3x/week)
No known allergies
HFD: DM and BA.
5. Gynecologic History:
Menarche 12 years old LMP Aug 15, 2010
Duration 3-5 days PMP July 15, 2010
Interval 30 days P0010 Complete Abortion
2006
Napkins used 3-5/ day
Dysmenorrhea Occ’l
Coitarche 17 years old
Sexual partners 9
OCP use None
6. HPI:
1 week PTA
epigastric pain, gnawing, non-radiating
temporarily relieved by Ranitidine
associated with fever
relieved by Paracetamol
No consult done
2 Days PTA
persistence of upper abdominal pain, more on the LUQ.
Consult at the OPD
CBC: wbc 21.54, Hb 8, Hct 26.3, Seg 85, Lymphocytes 3
Advised admission-refused; promised to come back if
with persistence of abdominal pain.
7. HPI:
AM PTA
hypogastric pain & RLQ recurred, PS: 8/10.
Follow up at PSH-OPD
TVS: normal uterus w/ cystic structure within RO consider
endometriotic cyst vs. corpus luteum cyst. Bilateral adnexal
tubulocystic structures cannot totally rule out bilateral tubo-
ovarian complex masses
Pregnancy test - negative.
Patient was then admitted.
13. MEDS:
Ranitidine IVTT
Clindamycin 900 mg q8 IV drip
Gentamycin 60 mg IVTT q8
MV + Iron PO
Paracetamol
Naproxen PO
2 units PRBC for transfusion
On admission:
17. 1st
HD (9/12):
S: Still with RLQ pain, PS:4/10, w/ vaginal spotting,
afebrile
O: BP: 110/70 HR:80 RR:20 T:36.8
Abd: Still with tenderness at RLQ
A: clinically stable
P: monitor for persistence of abdominal pain
For repeat CBC after 2 units of PRBC
Continue meds
18. 2nd
HD (9/13):
S: still with RLQ pain, PS: 2/10, afebrile, no more
vaginal spotting
O: BP: 110/80 HR:68 RR:20 T:36.7
Abd: still with tenderness at the RLQ
A: clinically stable
P: continue meds
20. 3rd
– 4th
HD (9/14-15):
S: No recurrence of pain, afebrile.
O: BP: 120/80 HR: 76 Temp:36.4
ABD: flat, NABS, soft, still w/ mild tenderness at the
hypogastric area
A: clinically stable
P: MGH
Clindamycin 300mg TID x 14days
Ofloxacin 400mg BID x 14 days
FF: after 2 weeks
21. Follow up @ OPD
Eight days
after discharge (9/23)
S: No recurrence of fever; No vaginal discharge
on & off epigastric pain
O: ABD: flat, NABS, soft, tenderness at epigastric area.
No more tenderness noted at the RLQ
A: PID resolved
T/C NUD
P: To continue stocks of Pantoprazole
22. Follow up @ OPD
Twelve days
after discharge (9/27)
S: still with on & off epigastric pain
relieved temporarily by PPI, assoc. with nausea
O: ABD: flat, NABS, soft, tenderness at the epigastric
area, no more pain at the RLQ
A: NUD
P: to continue PPI
:to consult with Gastro specialist if with persistence of
epigastric pain for UGIE
23. Follow up @ OPD
Fourteen days
after discharge (9/29)
Relief of epigastric pain was noted
No follow up done with her Gynecologist
Did not comply with the follow up TVS
Completed the 14 days take home antibiotic
24. DISCUSSIONDISCUSSION
PID is an infection in
the upper genital tract Includes:
1. endometritis
2.salpingitis
3. oophoritis
4.myometritis
5.uterine serosa & broad
ligaments (parametritis)
6.pelvic peritoneum
25. Acute PID
ascending infection from the bacterial flora of the
vagina and cervix in more than 99%
occurs along the mucosal surface, resulting in
bacterial colonization and infection of the
endometrium and fallopian tubes.
may extend to the ovaries and nearby peritoneum
and rarely into the broad ligament and pelvic
blood vessels.
26. May result from:
transperitoneal spread of infectious material
perforated appendix or intraabdominal abscess,
hematogenous & lymphatic spread
to the tubes or ovaries in <1%
>20 species of microorganisms
cultured from direct aspiration of purulent material
from infected tubes
ages 16 to 25 years old
27. 85% of infections
spontaneous in sexually active females.
15% of infections
develop after procedures that break the cervical mucus
barrier, allowing the vaginal flora to colonize the upper
genital tract
endometrial biopsy, curettage, (IUD) insertion,
hystero-salpingography, and hysteroscopy.
28. Rare in women who are amenorrheic or not
sexually active
When PID is found in the postmenopausal
woman, genital malignancies; diabetes; or
concurrent intestinal diseases (diverticulitis,
appendicitis,or carcinoma are usually discovered)
29. Complications of PID:
infertility due to tubal
obstruction
ectopic pregnancy
increases 6- to 10-fold
chronic pelvic pain
increases 4-fold.
The incidence of
infertility following acute
PID varies from 6% to
60%
31. Diagnosis:
Laparoscopy
most accurate method
with direct visualization of the internal female
organs
Ultrasound
view the pelvic area to see if fallopian tubes are
enlarged or an abscess is present
Leukocytosis
is not a reliable indicator of acute PID nor does it
correlate with the need for hospitalization
32. Diagnosis:
ESR
elevated (>15 mm/hr) in 75% of women with
laparoscopically confirmed acute pelvic infection.
B-HCG
to rule out ectopic pregnancy
Gram stain
examine the endocervical mucus for
inflammatory cells for N. gonorrhoeae and C.
trachomatis
33.
34.
35.
36. Criteria for hospitalization
surgical emergency cannot be excluded
patient is pregnant
patient does not respond clinically to oral
antibiotic
patient is unable to follow/tolerate an oral
regimen
patient has severe illness, N/V & high fever
patient has a tubo-ovarian abscess
37. Treatment for PID:
PID can be cured with antibiotics
Any damage that has already been done to a woman's
pelvic organs (uterus, fallopian tubes, and ovaries)
before treatment will not be reversed.
Early treatment for PID is very important.
38. CDC OPD Management
Regimen A
Levofloxacin 500 mg PO OD for 14 days or
Ofloxacin 400 mg PO OD for 14 days with or
without
Metronidazole 500 mg PO bid for 14 days
From Centers for Disease Control and Prevention: 2006
Guidelines for treatment of sexually transmitted diseases.
MMWR 55:11, 2006.
39. CDC OPD Management
Regimen B
Ceftriaxone 250 mg IM in a single dose or
Cefoxitin 2 g IM in a single dose and
probenecid 1 g PO single dose or
Other parenteral 3rd
Gen cephalosporin (e.g.,
ceftizoxime or cefotaxime)plus
Doxycycline 100 mg PO bid for 14 days with or
without
Metronidazole 500 mg PO bid for 14 days
From Centers for Disease Control and Prevention: 2006
Guidelines for treatment of sexually transmitted diseases.
MMWR 55:11, 2006.
40. CDC Inpatient Management
Parenteral Regimen A
Cefotetan 2 g IV every 12 hours OR
Cefoxitin 2 g IV every 6 hours PLUS
Doxycycline 100 mg PO or IV every 12 hours
From Centers for Disease Control and Prevention: 2006
Guidelines for treatment of sexually transmitted diseases.
MMWR 55:11, 2006
41. CDC Inpatient Management
Parenteral Regimen B
Clindamycin 900 mg IV every 8 hours PLUS
Gentamicin:
LD: IV or IM (2 mg/kg of body weight)
MD: (1.5 mg/kg) every 8 hours
From Centers for Disease Control and Prevention: 2006
Guidelines for treatment of sexually transmitted diseases.
MMWR 55:11, 2006
42. Alternative Parenteral Regimens
1) Levofloxacin 500 mg IV OD OR
Ofloxacin 400 mg IV q12 hours WITH or WITHOUT
Metronidazole 500 mg IV q8 hours
2) Ampicillin/Sulbactam 3g IV q6 hours PLUS
Doxycycline 100 mg PO or IV q12 hours
43. Prevention:
abstain from sexual intercourse
to be in a monogamous relationship with a
partner who has been tested & known to be
uninfected.
Latex male condoms use
CDC : Yearly Chlamydia testing:
1. sexually active women age 25 or younger
2. multiple sex partners (high risk for Chlamydia)
3. all pregnant women
44. Prevention:
Any genital symptoms:
unusual sore
discharge with odor
dysuria or bleeding between menstrual cycles
could mean an STD infection
If she has any of these symptoms, should consult
a health care provider immediately
63. Family Genogram
Rosalina Felix, 89 Bening, 60’s
Josepfina,
47
?
Alfredo, Sr.
Pu Family Kris Family
? ?
I
II
Elizabeth Alfred, Victo
rino
Joel
Babyle
ne
Legend:
• HPN
• Vaginal Bleeding
• PUD
III
?
•
•
•
Raymond,
24
Dina, 21
PSH OPD
Eric 27
Erwin 25
Jerry 19
65. A P G A R
PSH, Sept 15, 2010
Dina Almost always
(2)
Some of the
time (1)
Hardly
ever (0)
ADAPTATION: I am satisfied that I can
turn to my family for help when
something is troubling me
PARTNERSHIP: I am satisfied with the
way my family talks over things with
me and shares problems with me
GROWTH: I am satisfied that my family
accepts and supports my wishes to take
on new activities and directions
AFFECTION: I am satisfied with the way
my family expresses affection and
responds to my emotions
RESOLVE: I am satisfied with the way
my family and I share time together
69. Smilkstein’s Cycle of Family FunctionSmilkstein’s Cycle of Family Function
DISEQUILIBRIUM
Family in
Equilibrium
Stressful Life Event:
Abdominal Pain
CRISIS:
Inadequate family
income
Adaptation:
Savings from her
salary and insurance
Emotional support
from her family &
partner
70.
71. Impact of Illness
Stage I – Onset of Illness
Stage II – Reaction to Diagnosis
(Impact phase)
Stage III – Major Therapeutic efforts
Stage IV – Early Adjustment to Outcome
(Recovery Phase)
Stage V – Adjustment to the Permanency of the
Outcome
72. PU - kRIS FAMILy
Nuclear Family
Externally Patriarchal, Internally Matriarchal
Stage of Family Cycle :
Launching Family
Stage in Family illness:
Stage IV: Early Adjustment to Outcome (Recovery)
APGAR Assessment :
Moderately Dysfunctional
73. Smilkstein’s Family Cycle : Adaptation
SCREEM:
Strength: Social, Religion, Economic & Medical
Weakness: Cultural, Educational & Economic
74. RECOMMENDATIONS
To the patient:
Abstinence
Maintain healthy sexual behavior (limiting the number
of sex partners )
To have one sexual partner (monogamous)
Use barriers methods (condoms, diaphragms & vaginal
spermicides)
Adopt appropriate health-care-seeking behavior (early
detection & treatment of C. trachomatis & N.
gonorrhoeae infection)
To be more active in Church activities
To stay away from her previous drinking buddies
75. To the Family:
To encourage the patient to follow up with her
attending physicians
To encourage the patient to continue her studies in
College
76. To the community:
Community health promotion and education:
a)advocacy that recommends safer sex practices
b)providing environments conducive to safer sexual
behaviors
c)strengthening community action
d)promoting healthy personal skills (by providing
information, education, and counseling)
e)orienting health services toward meeting all health
needs
77. To the community:
High-quality clinical care that is accessible to persons
with STD should be developed and maintained
testing for HIV, Pap-smear screening, and drug &
family- planning counseling
Partner notification - implies a public health process
that informs persons directly exposed to an STD of
their status so they may be evaluated and treated
Male partners of women w/ PID have infection rates
up to 53% for chlamydia & 41% for gonorrhea
78. To the community:
Training of health-care providers
MD’s interested in STD will need to complement
their traditional diagnostic & therapeutic skills with
training in behavioral science
Skills to obtain an appropriate and complete sex
history, including details in sex practices and
partners, must be taught
84. REFERENCE LIST
1) Pelvic Inflammatory Disease: Guidelines for
Prevention and Management (CDC)
2) Comprehensive Gynecology 5th Ed
3) The Filipino Physician Today 2nd
Edition
4) Harrison’s IM, 17th
Edition
Editor's Notes
Clindamycin is for infections caused by susceptible anaerobic bacteria, for serious infections due to streptococci, pneumococci, and staphylococci
Gentamycin is indicated for infections caused by susceptible strains: Pseudomonas aeruginosa, Proteus species, Escherichia coli, Klebsiella - Enterobacter-Serratia species, Citrobacter species, and Staphylococcus species
Clindamycin-G+ cocci & G- bacteria & anaerobes inc. B. fragilis but minimal activity to G- enteric rods.
Ofloxacin are active against G- Aerobes but poor activity to G+ cocci & anaerobes.
