Where you are:
You are F2 in A&E.Who the patient is:
Tanya Morris, 30 years old, presented to the hospital complaining of right lower abdominal pain (RIF).What you must do:
Talk to the patient, discuss initial management and address her concerns.
D: What brought you to the hospital?
P: I have tummy pain. (P1)
SOCRATES
D: May I know where the pain is exactly?
P: It’s here doctor. In my right lower tummy.
D: When did the pain start?
P: It started 2-3 days ago.
D: What were you doing when the pain started?
P: I was sitting at home when it started doctor.
D: Is it continuous or comes and goes?
P: The pain is always there since it started.
D: Has it been the same?
P: It is getting worse.
D: What type of pain is it?
P: It is a dull pain.
D: Does it go anywhere?
P: No.
D: Have you taken any medication for it?
P: I took paracetamol, but it didn’t work.
D: How many tablets have you taken?
P: Just two tablets whenever I had pain.
D: Is there anything that makes it better or worse?
P: No.
D: Could you please score the pain on a scale of 1 to 10, with 1 being no pain and 10 being the most severe pain you have ever experienced.
P: Around 5.
D: Anything else?
P: I have discharge from my front passage. (P1)
TRAC
D: When did the discharge start?
P: 2-3 days ago.
D: What is the colour of discharge?
P: Yellowy, green.
D: Is there any blood in it?
P: No.
D: Is there any smell?
P: Yes doctor, it smells bad.
D: How much was the discharge?
P: Not too much.
D: Anything else?
P: No.
DDs
D: Did you have any fever or flu-like symptoms?
P: No/Yes I had a temperature. (+ve finding)
D: Were you feeling sick?
P: Yes for the past 2-3 days (+ve finding)
D: Did you vomit?
P: No.
D: Any pain or burning sensation while passing urine?
P: No.
FLAWS
D: Any weight loss? (Malignancy)
P: No.
D: Any lumps or bumps in body?
P: No.
D: Any change in appetite?
P: No.
D: Any night sweating?
P: No.
(P2)
D: Have you had any of these symptoms before?
P: No.
D: Have you been diagnosed with any medical condition in the past.
P: No.
D: Do you know if you have any cyst in your ovaries or any sexually transmitted infections before?
P: No.
DESA
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
P: Yes/No
D: Tell me about your diet.
P: I eat healthy.
D: Are you physically active?
P: Yes/No
MAFTOSA
D: Are you currently taking any medications, over-the-counter drugs, or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous surgeries or procedures?
P: No.
D: Any family history of health-related condition?
P: No.
(P4)
D: When was your last menstrual period?
P: 2/3 weeks ago.
D: Are they regular?
P: Yes.
D: Any bleeding or spotting in-between your periods?
P: No.
D: Any painful or heavy periods?
P: No.
D: Have you been pregnant before?
P: No.
D: Do you use any method of contraception?
P: Yes, I have coil inserted. (Risk factor)
D: Since when?
P: About three years now.
D: Is it in place?
P: Yes.
D: Were there any issues with the contraception used?
P: No.
D: Are you up to date with your pap smear?
P: Yes.
Sexual history
D: Sorry I need to ask you some sensitive questions is that OK?
P: Ok doctor.
D: Are you currently sexually active?
P: Yes.
D: When did you last have sexual activity?
P: Me and my boyfriend tried yesterday but I was in too much pain.
D: Do you have a stable partner?
P: Yes.
D: For how long you have been in this relationship?
P: I met my partner 2 weeks ago. (New partner <6 months, ask about previous partners).
D: Have you had any other partners recently?
P: Yes, I had two other partners before him recently.
D: What kind of sexual contact do you have, vaginal, anal, oral?
P: Vaginal/Oral.
D: Do you practice safe sex, by that I mean do you use condoms?
P: No. (Advise on having safe sex in management)
D: When was the last time you had unprotected sex?
P: Yesterday when we were trying…
D: And you already said you are feeling pain during or after sex?
P: Yes.
D: Any bleeding after sex?
P: No.
Examination
D: If it’s OK with you I would like to check your vitals and examine your tummy and take some swabs through a speculum examination.
I would also like to send for some initial investigations including routine blood test and
urine test.
Examiner: Right adnexal tenderness and cervical excitation.
Provisional diagnosis:
D: From our assessment, I suspect you have a condition called Pelvic Inflammatory
Disease in short (PID). This is an infection around your womb and surrounding
structures including the ovaries and the tubes connecting your ovaries to your womb.
This is caused by some bacteria that has travelled up into your womb.
Management
Urgent admission if :
• pregnant (to exclude ectopic pregnancy)
• symptoms are severe (such as nausea, vomiting and a high fever)
• signs of pelvic peritonitis
• an abscess is suspected
• unable to take oral antibiotics and need to be given them through a drip (intravenously)
• Suspected appendicitis
Senior
Investigations:
• Swabs are usually taken from the inside of your vagina and cervix. These are sent to a laboratory to look for signs of a bacterial infection and identify the bacteria responsible.
• Urine test
• Blood test
• Pregnancy test
• An ultrasound scan, which is usually carried out using a probe passed through the vagina (transvaginal ultrasound).
• In some cases, laparoscopy (keyhole surgery) may be used to diagnose PID. A laparoscopy is a minor operation where 2 small cuts are made in the abdomen. A thin camera is inserted so the doctor can look at your internal organs and, if necessary, take tissue samples. This is usually only done in more severe cases where there may be other possible causes of the symptoms, such as appendicitis.
Symptomatic:
- Antibiotics needs to be started quickly, before the results of the swabs are available.
– PID is usually caused by a variety of different bacteria. This means you’ll be given
a mixture of antibiotics to cover the most likely infections.
– You’ll usually have to take the antibiotic tablets for 14 days, sometimes beginning
with a single antibiotic injection.
– It’s very important to complete the entire course of antibiotics, even if you’re
feeling better, to help ensure the infection is properly cleared.
– In severe cases, you may have to be admitted to hospital to receive antibiotics through a drip in your arm (intravenously). - If you have pain around your pelvis or tummy, you can take painkillers such as
paracetamol or ibuprofen while you’re being treated with antibiotics.
Treating risk factors
• If you have an intrauterine device (IUD) fitted, you may be advised to have it
removed if your symptoms haven’t improved within a few days, as it may be the cause
of the infection.
• Treating sexual partners any sexual partners you have been with in the 6 months
before your symptoms started should be tested and treated to stop the infection
recurring or being spread to others, even if no specific cause is identified.
– PID can occur in long-term relationships where neither partner has had sex with
anyone else.
– It’s more likely to return if both partners aren’t treated at the same time.
– We can help you contact your previous partners. This can usually be done
anonymously if you prefer.
- You should avoid having sex until both you and your partner have completed the
course of treatment. - You can reduce your risk of PID by always using condoms with a new sexual
partner until they have had a sexual health check. - It is recommended to do screening for STIs regularly.
Follow-up
- A follow-up appointment 3 days after starting treatment to check if the
antibiotics are working. - If the antibiotics seem to be working, another follow-up appointment is given at
the end of the course to check if treatment has been successful.
Safety netting
- If your symptoms haven’t started to improve within 3 days, you may be advised
to attend hospital for further tests and treatment. - If you develop any fever or redness, heat, swelling around your private parts or
groin area, any burning sensation while passing urine, any cloudy or smelly urine
please come back to us. - We usually offer HIV test for those who have sexually transmitted infections. Do
you wish to have one?
Concerns:
P: Why do I have this?
D: It has many causes, the coil can be one of the causes, one of the commonest causes of PID is sexually transmitted infections.
P: Is my partner cheating on me?
D: It does not mean that your partner is cheating on you. These bacteria can stay in
your body for many months before causing any symptoms. You/He might have got this infection from your/his previous relationships.
P: What are the complications of it?
D: This condition can lead to some complications in pregnancy and can also lead to
infertility.