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Case 6.4 Pelvic Pain

By Meredith Scannell, PhD, MSN, MPH, CNM, CEN, SANE‐A

SUBJECTIVE

Shanae is a 32‐year‐old female who presents with lower abdominal pain and fever. Fevers at home range between 99.4°F to a maximum of 101.7°F. She describes the lower abdominal pain as a constant dull ache, nonradiating, with a pain scale ranging from 5/10 to 8/10. The pain is worse with sexual intercourse. Shanae is taking acetaminophen 650 mg every 4 hours with minimal relief. She reports general malaise and that for the past 2 weeks she has been having heavy, purulent vaginal discharge. Three weeks ago, Shanae went to an urgent care clinic for dysuria. At that time, there was concern about a sexual transmitted infection and Shanae was treated for gonorrhea and chlamydia.

Past medical history: Polycystic ovarian syndrome, gonorrhea, herpes simplex virus type‐2

Gynecologic history: Two abnormal Pap smears requiring repeat testing and cone biopsy with negative results.

Menstrual history: Menstrual cycles irregular between 28 and 35 days, lasting 5–7 days of heavy bleeding. LMP 1 week ago.

Family history: Mother with history of cervical cancer and died at the age of 38, father with alcohol and substance abuse, no other history known.

Sexual history: Shanae reports having a poor sexual relationship with her husband, from whom she is separated. She left her husband after finding out he was having extramarital relationships and has engaged in several sexual relationships of her own. She now reports current sexual activity as intercourse with only one partner. She and her partner use condoms on most occasions; however, there has been a few occasions when they did not use condoms. She is currently satisfied with her sexual partner with whom she engages in vaginal, oral, and rectal sexual intercourse.

Substance use: Shanae denies use of tobacco. She reports occasional alcohol use of 1–2 drinks per month. She reports daily or near daily smoking of marijuana and has used cocaine in the distant past, none recently.

Safety: Shanae reports feeling safe at home and in her current relationship. She says that the relationship with her husband was beginning to feel unsafe due to constant fighting. Since the separation, she has had no safety concerns and in the process of finalizing a divorce.

Medications: Ibuprofen 600 mg as needed, OCP (Yasmin) once daily.

Allergies: NKDA,

OBJECTIVE

General: Shanae is pleasant but appears in distress, guarding her abdomen.

Vital signs: Temperature: 100.4°F; BP: 100/52; HR: 110; respirations: 24.

Skin: Hot to touch, no lesions, no rashes.

Abdomen: Abdomen + bowel sounds, soft, nondistended. Positive suprapubic pain elicited upon palpation. No rebound tenderness, Turner sign, or Cullen sign.

Pelvic: Cervix midline, friable cervical OS; yellow discharge noted from the OS. Positive cervical motion tenderness. No lymphadenopathy and no adnexal masses.

Rectal: No lesions, no masses; normal sphincter tone.

CRITICAL THINKING

1 What is the most likely differential diagnosis in this case?___Ectopic pregnancy___Pyelonephritis___Pelvic inflammatory disease

2 Which diagnostic tests are required in this case and why?___CBC___Nucleic acid amplification tests (NAAT)___Beta hCG___HIV___Wet mount___Treponema pallidum___Transvaginal ultrasound

3 What is the plan of treatment?

4 What are the plans for follow‐up care?

5 What health education should be provided to this patient?

6 Are there any standardized guidelines that should be used to treat this case? If so, what are they?