An 18-year-old, nulliparous woman comes to the office with lower abdominal pain, nausea, and vomiting for the past day. She has been unable to tolerate food or water for the past 8 hours. The patient is sexually active and uses oral contraceptive pills. She has had 3 lifetime sexual partners. Her last menstrual period was 15 days ago. The patient has no medication allergies. Temperature is 39 C (102.2 F), blood pressure is 100/70 mm Hg, and pulse is 110/min. Physical examination reveals dry mucous membranes and delayed capillary refill. The abdomen has diffuse tenderness over the lower quadrants. The external genitalia have no abnormalities; speculum examination shows purulent discharge from the cervical os. The uterus is small, anteverted, and tender to palpation and motion. The adnexa are markedly tender bilaterally, with no palpable masses. Cervical nucleic acid amplification testing is pending. Urine pregnancy test is negative. Laboratory results are as follows: Which of the following is the best next step in management of this patient?

Question

An 18-year-old, nulliparous woman comes to the office with lower abdominal pain, nausea, and vomiting for the past day.  She has been unable to tolerate food or water for the past 8 hours.  The patient is sexually active and uses oral contraceptive pills.  She has had 3 lifetime sexual partners.  Her last menstrual period was 15 days ago.  The patient has no medication allergies.  Temperature is 39 C (102.2 F), blood pressure is 100/70 mm Hg, and pulse is 110/min.  Physical examination reveals dry mucous membranes and delayed capillary refill.  The abdomen has diffuse tenderness over the lower quadrants.  The external genitalia have no abnormalities; speculum examination shows purulent discharge from the cervical os.  The uterus is small, anteverted, and tender to palpation and motion.  The adnexa are markedly tender bilaterally, with no palpable masses.  Cervical nucleic acid amplification testing is pending.  Urine pregnancy test is negative.  Laboratory results are as follows:  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d983_e83d_bc81_5579cec3c768_MD0003_00 This patient has fever, lower abdominal pain, purulent cervical discharge, and cervical motion and adnexal tenderness, findings consistent with pelvic inflammatory disease (PID). PID is typically preceded by cervicitis due to Neisseria gonorrhoeae or Chlamydia trachomatis infection, which disrupts the barrier to the upper genital tract (eg, uterus, fallopian tubes), allowing a polymicrobial infection to develop in a normally sterile area. PID is treated with empiric, broad-spectrum antibiotics. The decision to treat either with inpatient or outpatient antibiotic therapy depends on several factors, including the following: Severity of presentation: Patients with high fever, severe pain, dehydration (eg, dry mucous membranes, delayed capillary refill), and inability to tolerate oral antibiotics (eg, nausea/vomiting) require inpatient treatment. In contrast, patients with a mild presentation (eg, no nausea/vomiting, pain manageable with over-the-counter medication) can be treated as an outpatient (Choices C, D, and E). Failure of outpatient therapy and/or presence of complications: PID can cause the formation of a tuboovarian abscess (eg, persistent fever, adnexal mass), perihepatitis (eg, new-onset pain in the right upper quadrant), or sepsis, all of which require inpatient treatment. Patient compliance: Inpatient treatment may benefit patients at risk for nonadherence to outpatient treatment (eg, adolescents). Therefore, this patient requires hospitalization, fluid resuscitation, and intravenous antibiotic therapy because she cannot tolerate food or water. A common regimen is an intravenous cephalosporin (eg, cefoxitin) plus oral doxycycline, which may require concomitant administration of an intravenous anti-nausea medication. Cephalosporins provide coverage for gram-negative bacilli (eg, Escherichia coli). Doxycycline treats gram-positive (eg, Streptococcus), gram-negative (eg, N gonorrhoeae), and atypical organisms (eg, C trachomatis, Mycoplasma). Metronidazole is added for additional anaerobic coverage when PID is complicated by a tuboovarian abscess. (Choice A) PID is typically polymicrobial and delayed treatment can increase the risk of severe and long-term complications (eg, perihepatitis, infertility). Therefore, both hospitalization and immediate broad-spectrum antibiotic treatment are required while nucleic acid amplification tests results are pending. Educational objective: Pelvic inflammatory disease may present with fever; diffuse lower abdominal pain; mucopurulent cervical discharge; and cervical motion, uterine, or adnexal tenderness. Indications for inpatient treatment with intravenous antibiotics include high fever, inability to tolerate oral antibiotics, and risk of nonadherence to outpatient treatment. References: Clinician perspectives on management of adolescents with pelvic inflammatory disease using standardized patient scenarios. (http://www.ncbi.nlm.nih.gov/pubmed/23680907) Pelvic inflammatory disease: diagnosis, management, and prevention. (http://www.ncbi.nlm.nih.gov/pubmed/31524362)

An 18-Year-Old, Nulliparous Woman Comes to the Office with Lower