Pelvic Inflammatory Disease: Diagnosis and Treatment

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  1. Diagnosis
  2. Plan/Therapeutics
  3. References
Name: Date: Time:
Age: Sex:
SUBJECTIVE
CC:
“The patient reported that she had been treated a week earlier for chlamydial infection and requested for further review. She denied complaining about any health concerns.”
HPI:
The patient had been diagnosed with chlamydia and had been treated a week earlier. The disorder had subsided by the time the patient came back to the hospital and by this time she had no complaint about any acute health concern.
Medications: (list with the reason formed )
PMH
Allergies:
None stated
Medication Intolerances:
None stated
Chronic Illnesses/Major traumas
Hypertension
Hospitalizations/Surgeries
None stated
The patient reports a history of hypertension. She, however, denies the use of medications for the same. She denies the history of any allergies.
Family History
The patient denied any history of a similar illness from family members.
Social History
Unknown
ROS
General
She denied experiencing signs of chills, weakness, fever, and fatigue.		 Cardiovascular
She reported a history of high blood pressure.
She denied experiencing leg pain, palpitations, and chest pain.
Skin
The patient denied experiencing skin dryness, hives, eczema, and itching.		 Respiratory
She denied experiencing incidences of a productive cough, pleurisy, and dyspnea.
Eyes
She denied experiencing eye pain, blurred vision, and discharge in the eyes.		 Gastrointestinal
She denied experiencing abdominal discomfort, loss of appetite, constipation, diarrhea, nausea, and vomiting.
Ears
She denied experiencing hearing impairment, ear discharge, ringing ears.		 Genitourinary/Gynecological
Denied the urgency, frequent painful urination, incontinence, urinary retention.
Nose/Mouth/Throat
She denied nasal obstruction, sinus infection, and epistaxis. She also denied tongue burning, voice changes, and postnasal discharge. 		Musculoskeletal
The patient denied experiencing muscle stiffness, restricted motion, paralysis, and joint pains.
Breast
She denied experiencing painful tenderness and discharge from the breast		 Neurological
She denied the incidence of speech disorders, memory loss tinging disorders, gait, numbness.
Heme/Lymph/Endo
She denied experiencing swollen lymph glands and blood clots. she also denied cold intolerance and fatigue		 Psychiatric
She denied experiencing hallucinations, mood changes, nervousness, disorientation, and behavioral.
OBJECTIVE
Weight 100lbBMI Temp98.20F BP138/87 mmHg
Height Pulse71 RespNormal quality with pulse oximetry of 99%
General Appearance
The patient appears to be well-groomed, well-nourished, alert, and awake.
Skin
The skin appears to be moist and no sign of allergy or dehydration.
HEENT
The head is normocephalic, has no masses, and atraumatic. No enlargement of parotid glands. No drooping of the face, the sinuses are not tender.
The eyelids have no lesions. The conjunctiva appears as pink while the sclera is white.
By inspecting the ears and nose externally, no masses or lesions were observed. By external otoscopic examination of the tympanic membrane and external auditory canal, they appear to be normal.
The lips have a normal color, there are no masses, lesions, or ulcers. The patches on oropharyngeal mucosa are observed as erythematous.
Cardiovascular
After palpation in the chest, no heaves were observed. The pulse rate is normal, S1 and S2 are normal. There are no rubs, no murmurs, and gallops.
Respiratory
The patient can breathe without effort. The patient doesn’t apply accessory muscles during respiration. The chest expands symmetrically, there is no cyanosis. Lungs are clear during auscultations.
Gastrointestinal
The abdomen appears to be softer and non-tender. No palpable masses and normal bowel sounds. There is no costovertebral angle and no hepatosplenomegaly.
Breast
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.
Genitourinary
The patient experiences no painful micturition.
Musculoskeletal
Through inspection, the symmetrical alignment of the joints was observed. No ecchymosis, nodules or lacerations, or any other sign of atrophy in the muscles. No cyanosis, clubbing, or petechiae on the extremities.
Neurological
The patient had his deep tendon reflex observed both in the lower and upper limbs, and the reflex was symmetrical. Sensory testing was normal, and the gait was intact. The cranial nerves 2-12 were tested and found to be grossly intact.
Psychiatric
Alert, awake, and oriented.
Lab Tests
Urinalysis:
Leucocytes – 0
Nitrite – 0
Urobilinogen – 0.2
Protein – + –
pH – 6.0
Specific gravity – 1.025
Ketone – 0
Bilirubin – 0
Glucose – 0
Special Tests
None

Diagnosis

Differential Diagnoses

  • Pelvic inflammatory disease is one of the disorders that might be affecting the patient. Udoji and Ness (2018) state that “painful urination is one of the common symptoms” of the pelvic inflammatory disease. While not all the symptoms are present, it is a definite differential diagnosis of the patient’s condition.
  • Candidiasis may also affect the vaginal area of the patient and present several negative outcomes similar to those of Chlamydia. A paper from Arendrup et al. (2018) states that candidiasis is a “relatively rare” condition. The symptoms of the infection are described similarly, but due to the rarity of the condition and lack of bodily discharge, it is only a differential diagnosis.
  • Trichomoniasis is another condition that might have a similar effect on the patient. Kissinger (2015) states that “Trichomonas vaginosis is the most common nonviral sexually transmitted infection” and examines several situations where patients experienced conditions that could be similar to chlamydia. However, the nature of the infection and previous history of the patient suggests that this could not be the final verdict.

Diagnosis

  • Hypertension is secondary to chlamydial infections. Subjective evidence of recent treatments for chlamydia shows that any complaints related to the genital area that the patient may or may not experience are likely to be caused by this condition is not fully treated. While the objective evidence reports no painful bodily functions, they may once more if the treatment is not finished. History of hypertension also suggests that the patient should be aware of the possibility of developing it.

Plan/Therapeutics

  • The patient was subjected to an ordered laboratory dipstick test. The results are supposed to be followed up by the patient and take recommendations provided on the treatment schedule per se by the consultants in the respective fields. The patient was advised to follow up on the treatment of hypertension. She needs monthly review to check on the blood pressure, by this, she will be able to commence the management of hypertension that she had reported.
  • If the tests confirm that the condition is still present in the patient a course of treatment should be prepared. Medication for the treatment should include a 100mg dose of Vibramycin or a similar antibiotic over at least seven days. Side effects of Vibramycin include a variety of gastrointestinal conditions such as the upset stomach, nausea, and vomiting. It is important to note that Vibramycin is a doxycycline drug. One of its effects is the increase of pressure inside the skull. Due to the patient’s possible hypertension, it is crucial to warn the patient that if side effects such as severe headaches or changes in vision occur, she must stop taking the drug immediately and report back for further examination. If the test results confirm the presence of hypertension, treatment should be prescribed. Hypertension is a relatively common condition that makes its presence likely. The treatment should include 12.5 to 25 mg of Chlorthalidone and ACE inhibitors taken to lower the blood pressure of the patient. Their side effects may include dry mouth, thirst, vomiting, nausea, muscle pain, weakness, uneven heartbeats, fatigue, dizziness, headaches, loss of taste, and the increased level of blood-potassium. Treatment should not coincide with chlamydia treatment because of the possible confusion between the side effects. Hypertension may result in highly negative outcomes for the patient if skull pressure side effects are not identified immediately.
  • The patient should be educated on the possible early symptoms of her condition, as well as ways to prevent it from happening in the future. The patient should also be educated on the risks that her condition is associated with and how she may improve it through nonmedical conditions.
  • They may include dieting and exercise routines designed to improve the condition of the patient’s cardiovascular system (Geisler, 2015). Additional hygiene products may be introduced into the patient’s shower routine to provide a nonmedication treatment for the disease.

References

Arendrup, M. C., Boekhout, T., Akova, M., Meis, J. F., Cornely, O. A., & Lortholary, O. (2014). ESCMID† and ECMM‡ joint clinical guidelines for the diagnosis and management of rare invasive yeast infections. Clinical Microbiology and Infection, 20, 76–98.

Geisler, W. M. (2015). Diagnosis and management of uncomplicated Chlamydia trachomatis infections in adolescents and adults: Summary of evidence reviewed for the 2015 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines. Clinical Infectious Diseases, 61, 774–784.

Kissinger, P. (2015). Epidemiology and treatment of trichomoniasis. Current Infectious Disease Reports, 17(6), 31.

Udoji, M. A., & Ness, T. J. (2018). Urogenital and pelvic pain. In Fundamentals of Pain Medicine (pp. 271–278). Cham, Switzerland: Springer, Cham.

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