Introduction
Pelvic inflammatory disease (PID) is a sexually transmitted infection that affects the uterus, oviducts, and ovaries. It is commonly caused by bacteria that induce chlamydia and gonorrhea. The common symptoms of PID are abdominal pain and tenderness, dyspareunia, burning sensation during urination, and vaginal discharge. Risk factors include multiple sexual partners, douching, and IUD use. The paper will use the SOAP analysis to examine subjective and objective data, as well as assess differential diagnoses. It will also provide a comprehensive plan of care and evaluate this diagnosis. It then offers the facilitators and barriers to optimal PID management before providing strategies to overcome these obstacles.
Patient Initials: T.Y.P Sex: Female Age: 28 years
Subjective Data
Chief Compliant: Increased vaginal discharge and lower abdominal pain for one week, a two-day history of urine frequency, pain, and a burning sensation during urination.
History of Present Illness: The patient recalls having unprotected sexual intercourse with her boyfriend, after which she developed a vaginal discharge and lower abdominal pains. The vaginal discharge was brown and foul-smelling, while the pain was increasing in intensity. The patient reports that two days ago, she started feeling pain and burning when urinating. Besides, she experiences an increased urine frequency. She states that the current symptoms are similar to those of a previous urinary tract infection (UTI).
PMH/Medical/Surgical History: She reports to have had two infections of gonorrhea and one infection of chlamydia. This year, she has had three infections of UTI. The patient has three children, but she had a total of four pregnancies (Gravida four Para three). She has no food or drug allergies, but she says that after taking the antibiotic trimethoprim/sulfamethoxazole, she developed rashes. She also had her tubes ligated two years ago.
Significant Family/Social History: She has had multiple sexual partners. She has three children. She is a single mother who lives with her boyfriend. She does not smoke, drink alcohol, or use any other drugs.
Review of Symptoms: She had her last Pap smear done six months ago (normal), and she denies breast discharge. However, her urine is dark in color.
Objective Data:
Vital Signs: BP 100/80; HR 80; RR 16; T 99.7 F; Wt. 120; Ht. 5 0; BMI 23.4.
The patient was in moderate stress during the general examination.
Physical Assessment Findings:
HEENT: Within normal limits.
Lymph Nodes: No lymphadenopathy.
Carotids: No abnormalities.
Lungs: Within normal limits.
Heart: Regular heart rate with a normal cardiac rhythm. S1 and S2 were heard, and they were normal.
Abdomen: The abdomen was soft, tender, and had an increased suprapubic tenderness.
Genital/Pelvic: There was cervical motion tenderness and adnexal tenderness. There was a foul-smelling vaginal discharge.
Rectum: Within normal limits.
Extremities/Pulses: Normal.
Neurologic: Within normal limits.
Laboratory and Diagnostic Test Results:
Leukocyte differential count: Neutrophils 68% (normal), Bands 7% (raised), Lymphocytes 13% (low), Monocytes 8% (normal), Eosinophil count 2% (normal).
Urinalysis: Urine is straw-colored (normal), specific gravity 1.015 (normal), pH 8.0 (normal), protein negative (normal), glucose negative (normal), ketones negative (normal), bacteria many (raised), leukocytes 10-15 (raised), and RBC 0-1 (normal) (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2016).
The urine Gram stain had gram -ve rods, while the discharge culture had gram -ve diplococci suggestive of Neisseria gonorrhea, sensitivities pending positive monoclonal antibody for chlamydia. KOH preparation (candidiasis), wet preparation (vulvovaginitis), and VDRL (syphilis) tests negative (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2016).
Assessment
Pelvic inflammatory disease (code N70). The subjective data include urine frequency, vaginal discharge, and lower abdominal pain. The objective data include adnexal tenderness and cervical motion tenderness.
Urinary tract infection, site not specified (code N39). The subjective data include lower abdominal pains, frequency, and pain and a burning feeling during urination. The objective data includes positive bacteria and leukocytes in the urine and suprapubic tenderness (CMS.gov, 2015).
Chlamydia infection (code A74). The subjective data include vaginal discharge and a burning sensation during urination. The objective data include the presence of gram -ve bacteria in urine and discharge and suprapubic tenderness (CMS.gov, 2015).
Plan of Care
Diagnosis is based on the clinical assessment (abdominal tenderness, cervical motion tenderness, and adnexal tenderness) and imaging modalities, such as abdominal ultrasonography and laparoscopy. Treating PID entails the use of a broad spectrum of antibiotics, such as clindamycin 900mg 8hourly, a gentamicin loading dose of 2mg/kg, and a maintenance dose of 1-5mg/kg 8hourly for two weeks (CDC, 2015).
Prevention strategies include regular testing for STIs, wiping from front to back to prevent entry of bacteria, avoiding douching, and safe sex practices, including condom usage and mutual monogamy (CDC, 2016).
Health promotion strategies include education on STIs through media campaigns. Prevention strategies, like proper condom distribution, also may lower the risk of infection. In addition, ensuring access, affordability, free screening, and rapid referrals helps to promote health (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2016).
The initial follow-up should occur 48-72hours after post-treatment to check drug efficacy. The next follow-up should take place after the completion of therapy. The patient should come three months and twelve months after treatment, after which standard check-ups may continue (CDC, 2015).
Evaluation of Priority Diagnosis
PID results from unprotected sexual intercourse, which causes the transfer of bacteria. The disease can also arise from inflammation caused by the disruption of normal barrier in the cervix from IUD insertion, abortion, and vaginal douching. These events may cause bacteria to ascend and cause infection (CDC, 2016).
Physical effects of PID may include infertility, abortions, the blindness of infants, and death. Psychological effects of PID include stress, depression, stigmatization, and psychosis. Possible effects on family members include burden from caregiving, financial constraints, social stigma, and discrimination. The key issues of discussion with the patient and family include the cost of treatment, lifestyle changes to cope with disease, complications, and follow-up treatment. The interdisciplinary team for the patient under discussion would comprise a gynecologist, a pharmacist, a nurse, counselors, and a public health worker. The team would help in the diagnosis, treatment, follow-up, counseling, and contact tracing.
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Facilitators and Barriers
A proper management of PID is facilitated by an early and regular screening, use of syndromic approach in the treatment of PID, adherence to therapy, patient follow-up, and contact tracing. Barriers to proper management of PID include a range of issues such as lack of availability of professional resources and training, lack of proper counseling, difficulties in maintaining the patients privacy, inadequate time for physicians to discuss sexual health with the patients, and lack of proper reimbursement of doctors. Various strategies can help overcome these barriers, including investing in proper physician training and allocating resources to improve risk assessment, diagnosis, and treatment, including counseling in both undergraduate and post-graduate programs to enable doctors to offer appropriate counseling and use of time-saving tools, like flowcharts and flipcharts, to aid in quick history taking. Use of closed-door interviews and limiting staff movement during consultations can help improve the confidentiality issue (Do, Minichiello, Hussain, & Khan, 2014).
Conclusion
In conclusion, PID is an STI mainly caused by the bacteria C. trachomatis and N. gonorrhea. It affects the uterus ovaries and oviducts. Clinical assessments and imaging help to diagnose PID. Treatment takes fourteen days and involves the use of a broad spectrum of antibiotics, such as gentamicin and clindamycin. Safe sex and regular screening help to prevent the condition. Examples of health promotion methods are mass education and condom distribution. Follow-up is done during treatment, three months after treatment, and twelve months treatment. PID is transmitted during unprotected sex, douching, and IUD use. The disease causes physical and psychological effects, including stress, infertility, depression, stigmatization, and death. The team involved in the management of PID comprises gynecologists, nurses, pharmacists, public health workers, and counselors. Facilitators of proper PID treatment include contact tracing, screening, and patient follow-up. Barriers include lack of training, inadequate counseling, lack of time, and difficulties in maintaining patient privacy.
