Sexual health for PLAB 1

A 19 year old woman has had bilateral lower abdominal pain and deep dyspareunia for three days, with an offensive vaginal discharge. Her temperature is 38.4°C. Vaginal examination shows marked cervical motion tenderness. A urinary pregnancy test is negative. What is the SINGLE most likely diagnosis?

1. Ectopic pregnancy A pregnancy growing outside the womb, which must be ruled out in any woman of childbearing age with pelvic pain. A pregnancy test is always needed. Here, pain on both sides with pain when the cervix is moved, and a negative pregnancy test points elsewhere.
2. Pelvic inflammatory disease correct Correct. Pain low in the belly on both sides, deep pain during sex, smelly discharge, fever, and pain when the cervix is moved, in a sexually active young woman. Pain on moving the cervix is the sign that points away from a bladder or bowel cause and toward an infection spreading up through the genital tract.
3. Appendicitis Pain that starts elsewhere and moves to the lower right side of the belly, with loss of appetite and tenderness right over that spot. But pain on both sides with pain when the cervix is moved, and a negative pregnancy test does not point to it.
4. Ovarian torsion Sudden severe pain on one side with vomiting and a lump felt near the ovary. It does not fit pain on both sides with pain when the cervix is moved, and a negative pregnancy test.
5. Endometriosis Pain that comes and goes with the monthly cycle, and pain during sex, over months to years, without fever or discharge. That does not match pain on both sides with pain when the cervix is moved, and a negative pregnancy test.

The point: Pelvic inflammatory disease (PID) is diagnosed by how the patient looks and feels, not by one test result, and doctors are told to treat it easily and quickly, because missing it can cause infertility, a pregnancy growing outside the womb, and long-term pelvic pain. Start treatment before swab results come back, cover gonorrhoea, chlamydia and germs that live without oxygen, do not remove anything, and trace sexual partners.

Source: NICE CKS — Pelvic inflammatory disease NICE · tier 1, national regulator or guidance

A 19 year old woman has had bilateral lower abdominal pain and deep dyspareunia for three days, with an offensive vaginal discharge. Her temperature is 38.4°C. Vaginal examination shows marked cervical motion tenderness. A urinary pregnancy test is negative. What is the SINGLE most appropriate initial investigation?

1. Endocervical swabs for gonorrhoea and chlamydia correct Correct. A sensitive lab test finds out which germ is causing it and lets her partner be told and treated, which is what stops her catching it again. It does not delay anything, because treatment starts on the same visit, before the result comes back.
2. Full blood count and CRP Backs up the picture but is not reliable enough on its own to say for certain whether PID is present or not. But pain on both sides with pain when the cervix is moved, and a negative pregnancy test does not point to it.
3. Pelvic ultrasound Looks for a pocket of pus around the tube and ovary rather than confirming PID itself. It does not fit pain on both sides with pain when the cervix is moved, and a negative pregnancy test.
4. High vaginal swab Picks up bacterial vaginosis and thrush, neither of which is what needs finding here. That does not match pain on both sides with pain when the cervix is moved, and a negative pregnancy test.
5. Laparoscopy A keyhole surgery test that is the most accurate way to confirm the diagnosis, but it is not used first. It is saved for when the diagnosis is unclear or treatment has not worked. Here, pain on both sides with pain when the cervix is moved, and a negative pregnancy test points elsewhere.

The point: Pelvic inflammatory disease (PID) is diagnosed by how the patient looks and feels, not by one test result, and doctors are told to treat it easily and quickly, because missing it can cause infertility, a pregnancy growing outside the womb, and long-term pelvic pain. Start treatment before swab results come back, cover gonorrhoea, chlamydia and germs that live without oxygen, do not remove anything, and trace sexual partners.

Source: NICE CKS — Pelvic inflammatory disease NICE · tier 1, national regulator or guidance

A 19 year old woman has had bilateral lower abdominal pain and deep dyspareunia for three days, with an offensive vaginal discharge. Her temperature is 38.4°C. Vaginal examination shows marked cervical motion tenderness. A urinary pregnancy test is negative. What is the SINGLE most appropriate immediate management?

1. Ceftriaxone, doxycycline and metronidazole correct Correct. Treatment given before results come back, covering three germs at once: ceftriaxone for gonorrhoea, doxycycline for chlamydia, and metronidazole for germs that live without oxygen. All three are needed because nobody can wait for the swab, and having more than one infection at once is common.
2. Metronidazole alone Covers only the germs that live without oxygen. It does not fit pain on both sides with pain when the cervix is moved, and a negative pregnancy test.
3. Admit for intravenous antibiotics For pregnancy, being severely unwell all over, a pocket of pus around the tube and ovary, or tablets not working. But pain on both sides with pain when the cervix is moved, and a negative pregnancy test does not point to it.
4. Await swab results before treating The single most harmful choice. Waiting is what damages the fallopian tubes, and. That does not match pain on both sides with pain when the cervix is moved, and a negative pregnancy test.
5. Remove the intrauterine device Not done as a routine step. The coil can usually stay in place unless there is no improvement after 72 hours. Here, pain on both sides with pain when the cervix is moved, and a negative pregnancy test points elsewhere.

The point: Pelvic inflammatory disease (PID) is diagnosed by how the patient looks and feels, not by one test result, and doctors are told to treat it easily and quickly, because missing it can cause infertility, a pregnancy growing outside the womb, and long-term pelvic pain. Start treatment before swab results come back, cover gonorrhoea, chlamydia and germs that live without oxygen, do not remove anything, and trace sexual partners.

Source: NICE CKS — Pelvic inflammatory disease NICE · tier 1, national regulator or guidance