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EBM

Group 2

Alan Rodrguez
Nayla Delgado
Ariel Gonzlez
EBM-Cases
OB-GYN
March 2, y
Name: JOC
MR#: 674945
Age: 21 y/o
Date of admission: 3/3/14
Date of interview: 3/8/14
G3P0120
CC: 21 y/o female presents with lower abdominal and lower back pain one day prior to
admission.
HPI: Case of a 21 y/o female G3P0120 with no history of SI, who was in her usual state
of health until one day prior to admission, when patient reports she developed lower
abdominal pain that radiated to her lower back, started gradually progressing to a 10/10
intensity, described as a stabbing with pressure. Denies headache, nausea, vomiting,
dizziness, diarrhea or constipation. Ibuprofen, 600 mg, alleviated pain but it returned and
prompted her to go to the ER. Patient reports dyspareunia 3 days prior to admission and
mild vaginal spotting on the day before admission, but denies vaginal discharge, dysuria,
urinary urgency or frequency, or vaginal itching. LMP: 2/20/14

Past history:
Chronic Illnesses:
Life long anemia (probably since menarche)
Hypoglycemia (14 year old)
Duplication anomaly of the uterus
Other: reports episodes of insomnia since still birth (December, 2013)
Childhood illnesses: non
Transfusions: none, accepts blood transfusion
Hospitalisations:
Labor induction (Dec, 2013)
Endometritis (Jan, 2014)
Trauma: none
Accidents: None
Immunisations:

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Group 2

Up to date
Surgery:
ELAP x ovarian cysts (2013),
D/C due to endometritis (Jan 2014),
Open appendectomy in childhood.
Medications: Folic Acid
Allergies: Penicillin and Seafood
Dysmenorrhea.

Obstetrics History:
SAB on first trimester (13 y/o)
SAB on first trimester (19 y/o)
SAB at 25 WGA, still-birth (21y/o)
G3P0120
Complications: SAB x 3
Gynecology History:
Menarche: 11 y/o
Menses: regular
Days of menses: 5 days
Intermenstrual bleeding: yes
Dysmenorrhea: yes
Menorrhagea: first 2 years since menarche
Pads: one pack of pads per day (first 2 years of menses), reduced to usage to 1.5 packs
per menstrual period (after the first 2 years)
Last Pap smear: 2012, Negative
History STD: none
Sexual history: currently active
First Coitus: 13 y/o
Current activity: only one partner
Protection: yes, intermittently
Contraception: never
Dyspareunia: yes, since 3 days prior to admission
Post-coital bleeding: no
LMP: 2/20/14

Personal and social History:

EBM

Group 2

Smoking: none, never


Alcohol: social drinker, 1 can of beer on weekends, 2 months ago.
Drugs: None, never
Diet: varied
Exercise: none
Religion: none
Physical exam findings: cervical motion tenderness, tenderness to palpation of uterus
and adnexa, lower left and right quadrant tenderness and bilateral CVA tenderness.
Significant lab findings: WBC: 11.04; Hgb: 14.8; Hct: 43.3%; Platelets: 304.
Pregnancy test: negative.

ROS:
General: general good health, no weight change, fever or chills
Skin: no rash or itching
Eyes: no visual acuity change, no blurriness
Ears/Nose: no decreased hearing, nose bleeding or runny nose
Mouth/throat: no oral ulcers/lesions, sore throat or hoarseness
Respiratory: no cough, sputum or shortness of breath
Cardiovascular: no chest pain, orthopnea or palpitations
Gastrointestinal: no change in appetite, yes to physiologic heartburn, no vomiting,
diarrhea or constipation, Pain on lower side of abdomen (see HPI)
Genitourinary: no pain while urinating, urgency, recurrence of waking at night to urinate
or incontinence, mild vaginal spotting.
Gynecological: G1P1A0, menarche, no vaginal bleeding or use of contraceptions
Musculoskeletal: no joint pain, swelling or stiffness, walking elicits back pain when not
under pain killer medications
Reticuloendothelial: refers getting easily sick from sick contact, believes to have some
immune difficulty.
Hematologic: no signs of sickle cell anemia or pallor
Neurologic: no weakness, seizures, head trauma or tremors
Psychiatric: no history of anxiety, panic or sadness
Sleep: normal sleeping, no insomnia, snoring or apnea

Physical Exam:
V/S:
T:36.9C
HR: 68

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Group 2
RR: 19
BP: 101/64
H: 58
W: 172 lbs

General: AA)x3
HEENT: PERRLA, EOMI and MM
Lungs: CTA x2
Heart RRR, no murmurs
Breast: Deferred
Abdomen: +BS, soft, depressible, tenderness upon palpation of bilateral lower
quadrants. There is positive bilateral costo-vertebral angle
Pelvic:
ext: ASA
BUS: -MINT
Vagina: w/e, w/s
Uterus: tender to palpation
Adnexa: tender to palpation, no masses were felt
Extremities: no lesions
Rectal: deferred
Labs:
CBC 3/7/14
WBC: 6.53
Hgb: 12.5
Hct: 37.6
Plt: 281
%Neutrophils: 50.8
%Lymphocytes: 36.3
Urinalysis 3/7/14
Negative for UTI (- Leukocyte esterase, - nitrates)
Imaging:
Endovaginal sonogram 3/3/14
Duplication anomaly of the uterus
Small amount of free pelvic fluid and small fluid collection on endocervical canal.

Differential Diagnosis:

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Group 2

PID (ICD 615.0):


Based on history, clinical findings and labs, but non of them prove to be highly
specific or sensitive for the disease. Patients with endocervical infections like PID
tend to be asymptomatic. On laparoscopic examination, 25% of these patient will be
positive for an upper tract infection. The CDC has established criteria to treat
empirically such as pelvic or lower abdominal pain, who is sexually active, and one
of the following: cervical motion tenderness, uterine or adnexal tenderness. PID
usually last 7 days. Most patients show clonal response after 48-72 hrs after
treatment; if treatment fails, laparoscopic evaluation is indicated. Our patient
presented with lower abdominal pain, cervical and adnexal tenderness. No
leukocytosis or fever. Transvaginal ultrasound showed free water on endocervical
canal. CVA tenderness with negative U/A results for UTI.
Ectopic Pregnancy (ICD9 639):
Only 50% of ectopic pregnancy present with the classical triad of pain, amenorrhea,
and vaginal bleeding. Transvaginal ultrasound and bHCG test should be done.
When bHCG levels rise to 1,200 to 1,500, the transvaginal ultrasound should see a
product of conception inside the uterine cavity. Showing at least a intradecidual line
sign. To confirm the diagnosis a laparoscopic exam should be performed to evaluate
the fallopian ducts and peritoneum. One must rule out the presence of fibroids,
because they can cause abnormal bleeding during menses. Our patient did not
have a product of conception inside the uterine cavity, but did have adnexal and
cervical tenderness. These finding are not suggestive of ectopic pregnancy. Vaginal
bleeding was not present in our patient, but ectopic pregnancies don't always
present with vaginal bleeding. Symptoms of amenorrhea were not reported.
Ruptured Ovarian Cyst (ICD9 620.2):
This diagnosis is not life-threatening, but shares symptomatic presentation with
ovarian torsion, tubo-ovarian abscesses or ectopic pregnancy. Culdocentesis should
be performed to obtain cyst material for cytology labs. This procedure has proven
inefficient, and has been substituted for simple ultrasonography and diagnostic
laparoscopy. Most patients with ovarian cysts are asymptomatic, they can be
discovered incidentally, but mostly through ultrasound and routine pelvic
examination. Rupture of cyst can cause sudden, unilateral, and sharp pelvic pain.
There can be abdominal distention and bleeding that is self-limited. Some
dyspareunia can be presented. Theca-Lutein cysts are usually bilateral and cause
dull bilateral pain. Our patient had bilateral adnexal tenderness, if hemorrhage
occurred, our patient might have had a diffusely tender abdomen, with rebound
tenderness and guarding. Malignancies are uncommon in patient younger than
35yrs. Transvaginal sonogram did not show any findings of ovarian mass or cyst on
the ovaries, thus discarding existence of cysts or chocolate cysts.

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Group 2

Discussion of Diagnosis, Differential Dx and Diagnostic:


This patient was admitted to the ER with stable vitals on the first day. Labs were sent
out to rule out infections (CBC,CMP, ESR, bHCG, etc.).On the second day, there was a
clinical suspicion that it was PID infection since the patient was sexually active, and
had no previous relevant ob-gyn history. bHCG test was performed and proved
negative (R/O ectopic pregnancy). Furthermore, an endovaginal sonogram revealed
free-water content in the uterine cavity. This prompted the empirical treatment for
PID, since culture results would take more time. Reassessment of treatment should be
done around 48-72 hrs. Treatment failure was observed, so Doxycycline was added;
some pain relief was observed 24 hrs later, along with a decrease in leukocyte (status
was non-leukocytosis before treatment; fever was never present). If the treatment
failed once again, then, reassess antibiotic treatment. Laparoscopic procedure would
be indicated to confirm PID or assess for ovarian cyst rupture, masses or possible
endometrioma.
Should discuss alternate diagnostic modalities supported by
evidence
These modalities are performed to improve diagnosis, but
are not necessary, nor indicated for usual management of
PID.
Laparoscopic confirmation
Transvaginal ultrasound, CT scan or MRI: that shows
thickening, fluid filled tubes with or w/o free pelvic
fluid or TOA.
Culdocentesis
Endometrial biopsy showing endometritis
Clinical findings:
oral temperature higher than 38.3C (101F)
Abnormal cervical or vaginal mucopurulent
discharge
Lekocytosis
Elevated ESR
Elevated CRP
Laboratory evidence of GC/Chlam (NAAT)
Was the initial evaluation adequate?
Since PID diagnosis is primarily through clinical findings:
oral temperature higher than 38.3C
Abnormal cervical discharge
Cervical motion tenderness
Uterine inflammation
Adnexal inflammation
Sexually active
Labs
CBC
CMP
U/A
NAAT (not always indicated)
RPR
HIV

EBM

Group 2
Transvaginal Ultrasound
Better than abdominal ultrasound. It is used to
evaluate for uterine abnormalities and pelvic masses.
Should you use additional or different diagnostic modalities in this
patient?
UTI
Endometriosis
Should the patient be considered for additional differential
diagnosis?
Ectopic Pregnancy
Endometritis

Reference #? Ariels
A comparison of two antibiotic regimen for treatment of PID by David E. Soper, MD and
Bernard Despres, DO. (1988) This paper tries to compare the effectiveness of the
combination of clindamycin/amikacin and cefoxitin/doxycycline in treatment of PID. This
is a double-blind randomised clinical trial where 62 women, clinically diagnosed with
PID. 31 of these patients where treated with cefoxitin and doxycycline and the other 28
received clindamycin and amikacin; response to therapy was assessed (P= not
significant) In conclusion, bot treatment options proved to be equally effective to treat
PID. The pertinence of this paper to our PICO question is because it further identified
factors such as the severity of disease and time to respond of treatment for PID. It also
provided more evidence of a high curing rate under randomised double-blind
parameters.
This papers strengths are in the comparison approach by assessing severity and time of
response to treatment. Thus making groups matching severity and clinical staging.
Its limitations are inthe population used, because it was limited to active military
personnel, low middle social class and with full medical coverage. Another weakness is
the low amount of n=62. Long term fertility should be the real parameter to assess
treatment effectiveness. A suggestion to increase the strength of this papers was to
perform a laparoscopy procedure to truly verify the grading parameters used to assess
severity. There is a stage in the study design where, after hospital discharge, the patient
continues a 10 day treatment with antibiotics PO at home. There is was no way of
assessing the compliance with treatment, besides a phone call.

According to the Canadian Task Force on Periodic Health Examination, this randomised
clinical trial would be classified as Evidence Level I.
In conclusion this paper shows that the two antibiotic demonstrate similar effectiveness.
There was no statistical difference between age, race, marital status, gravidity, parity,
contraceptives and history of PID. The cure rate was 71.4, and there were no difference
in response rate or days of stay in the hospital.

EBM

Group 2
Reference #5

Treatment of Acute Pelvic Inflammatory Disease (2011) by Richard L. Sweet is a metaanalysis that used etiological account, treatment concepts, antimicrobial regimes,
management and outcomes about PID. It focuses on verifying the incidence of bacteria
that cause Pelvic Inflammatory disease infections. It also looks for the antimicrobial
treatment modalities that have been used in the clinical setting. The pertinence of this
study is that it gives a further account of what has been done to treat PID and to raise
the question on what information is missing about PID. One of his paragraphs he
informs that there should be a study that assesses the true effectiveness of treatment for
PID comparing pregnancy outcomes. This papers helps our PICO question by providing
evidence of how many research papers are available for each treatment regime. The
two most researched regimens are the parenteral clindamycin/aminoglycoside (11
studies, 470 cured patients, 92% curing rate), cefoxitin/doxycycline ( 9 studies, 836
cured patients, 95% curing rate) and cefotetan/doxycycline (3 studies, 174 cured
patients and a 94% curing rate).
This paper is relevant because it gives a thorough account of what is known and what is
missing about PID; and what treatment options can be assessed for further research on
effectiveness.
This study is classified as Evidence Level II-3 according to the criteria of the Canadian
Task Force on Periodic Health Examination. This paper is reliable because it has many
cross-references that complement each other. Its main strength is that its from the year
2011, and most of its references are recent. Since this paper offers a review perspective,
it does offer a relevant point about PID, and its effectiveness in reducing infertility or
other obstetric complications.