This document presents the case of a 21-year-old female admitted for abdominal pain. She has a history of smoking and is diagnosed with pelvic inflammatory disease (PID) based on symptoms of abdominal pain and vaginal discharge. She is treated with antibiotics and blood transfusions and shows improvement. The document also discusses PID, its causes, symptoms, diagnosis and treatment guidelines. It profiles the patient's family and their economic situation.

1. November 2010

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.

8. PHYSICAL EXAMINATION
BP: 90/60 HR: 88 RR:20 Temp: 37.2
Wt: 45kgs
Skin: no pallor, warm
HEENT: Pink palpebral conjunctiva, anicteric sclera,
no tonsillopharyngeal congestion
C/L: Equal chest expansion, clear breath sounds
CVS: Distinct heart sounds, Normal rate, regular
rhythm

9. PHYSICAL EXAMINATION
Abd: flat, Normoactive bowel sounds, soft but with
tenderness & voluntary guarding at the LUQ
& RLQ
GUT: (-) KPS
Ext: strong pulses

10. IE:
(+) wart-like lesion at the vaginal wall
Cervix-closed
(+) bloody vaginal discharge
BPE: Introitus: nulliparous
Cervix : no cervical motion tenderness
Uterus: small
Adnexa: tenderness on deep palpation
Discharge: bloody vaginal discharge

11. Impression:

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:

14. Labs: 9/09/10
OPD
9/11/10
WBC 21.54 12.98
Seg 85 74
Lym 3 16
Hb 8 7.4
Hct 26.3 24.6
PLT 581 763

15. Labs:
Transvaginal UTZ:
Normal sized anteverted uterus w/ isoechoic
endometrium
Cystic structure within the RO. Consider
endometriotic cyst vs. corpus luteum cyst
Unremarkable LO
Bilateral Adnexal Tubulocystic structures. Consider
dilated FT. Cannot totally rule out bilateral
tuboovarian complex masses. Minimal clear cul de sac
fluid.

16. Labs:
Pregtest: (OPD): negative
U/A: unremarkable
Bloodtype: O (+)
Creatinine: 0.87
Peripheral Blood Smear:
RBC: markedly microcytic,
hypochromic.
Leucocytosis with
Neutrophilic predominance
Thrombocytosis

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

19. Labs:
9/12/10
(1st
HD)
9/13/10
(2nd
HD)
WBC 9.99 9.44
Seg 69 70
Lym 18 18
Hb 9.7 From 7.4  10.9
Hct 31.4 36.3
Plt 624 833

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%

30. Clinical Manifestations:
Silent/asymptomatic PID
lower abdominal pain
Fever
vaginal discharge
dyspareunia
dysuria
irregular menstrual
bleeding
RUQ pain (rare)

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

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

45. FAMILY PROFILE
Alfred:
Father
47 y.o
Unemployed
Previously: Inter-island vessel crew
Asthmatic-No maintenance meds
Alcoholic drinker (Tanduay daily)

46. FAMILY PROFILE
Josefina
Mother
47 yo
Teacher
HPN: Metoprolol PRN
Anemia 2* profuse
menstruation

47. FAMILY PROFILE
Eric
27 yo
Eldest
Teacher
Police Officer
No medical Problem
No Vices

48. FAMILY PROFILE
Erwin
25 yo
2nd child
2nd
year college level
Unemployed
Married with 1 child
No medical Problem

49. FAMILY PROFILE
Dina
21 yo
Index Patient
1st
Year College Level
Call Center Agent in
Xlibris
No Medical Problem

50. FAMILY PROFILE
Jerry
19 yo
4th
child/ youngest
2nd
Year College Student
in Camotes
No Medical Problem

51. THE HOUSE
Hallway

52. KITCHEN
Comfort Room

54. Bedroom

55. FAMILY LIFE LINE

56. 1983
Alfredo working in an inter-island
vessel

57. He met Josefina while onboard the vessel for Cebu City.
Became lovers and got married immediately after Josefina got
pregnant

58. 1983: Eric was born
1985: Erwin was born
1989: Dina was born
1991: Jerry was born

59. Economic Profile
Total Monthly Income: 50,000
Basic Salary: 22,000
C0mmission Average: 30,ooo
Total Expenses/month: 31,100 (64.4 %)
Savings: 18,900 (37.8 %)
Food: 7,000 (14 %)
House Rental (Electric, Internet): 7,100 (14.2 %)
Clothing: 5,000 (10 %)
Miscellaneous: 7,000 (14 %)
Church Donation: 5,000 (10 %)

60. Economic

61. Admission:
Additional Expenses: (20,000)
Medicine: 4,600
Total Hospital Bill: Insurance + 9,400
Food & Taxi Fare for the patient’s SO: 6,000

62. Family Assessment Tools

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

64. Family Circle
Patient
Eric
Raymond
Erwin
Jerry
Josefi
na-
mothe
r
Alfred-
father
Aunt Babeth
Aunt Babylyn

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 

66. A P G A R
6

67. SOCIAL
CULTURAL
RELIGIOn
EDUCATIOnAL
ECOnOMICS
MEDICAL

68. RESOURCE
(STRENGTH)
PATHOLOGY
(WEAKNESS)
SOCIAL 
CULTURAL 
RELIGIOUS 
EDUCATIONAL 
ECONOMIC 
MEDICAL 
S C R E E MS C R E E M

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

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

80. FamilyFamily
membermember
ProblemsProblems primaryprimary
preventionprevention
2ndry2ndry
preventionprevention
TertiaryTertiary
preventionprevention
Erick No medical
problem
Inform them
of the effects
of BA & HPN,
discuss the
effects of
alcohol
Erwin No medical
problem
Inform them
of the effects
of BA & HPN,
discuss the
effects of
alcohol

81. FamilyFamily
membermember
ProblemsProblems primaryprimary
preventionprevention
2ndry2ndry
preventionprevention
TertiaryTertiary
preventionprevention
Dina PID Teach safe sex
practices, use
condom,
Abstinence;
education to
prevent
recurrent
infection.
screening for
chlamydia and
gonorrhea;
screening for
active cervicitis;
treatment of
sexual partners
To complete
her Home
meds & to
repeat
Abdomial
UTZ
Jerry No medical
problem
To avoid
alcoholic
beverages
and smoking
Exercise
regularly

82. FamilyFamily
membermember
ProblemsProblems primaryprimary
preventionprevention
2ndry2ndry
preventionprevention
TertiaryTertiary
preventionprevention
Alfred Asthmatic;
alcoholic
drinker
avoid having
cats or dogs in
the home,
avoid
smoking;
limit intake of
alcoholic
beverages
Prompt treatment
with
Bronchodilators,
advise for sgpt
monitoring
Allergens to
which a person
is sensitized
should be
identified
Josefina HPN Limit intake of
high
cholesterol,
salty food,
increase
physical
activity
BP monitoring,
LIPID panel,
Creatinine
monitoring
To take her
maintenance
medications
regularlly

83. Pls visit: http://crisbertcualteros.page.tl

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