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Old 12-01-2011
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ObGyn Right Upper Quadrant Pain + Tender Cervix

A 24-year-old woman has fever, right upper quadrant pain, and lower abdominal pain. She reports having multiple sexual partners and does not use condoms. She has no medical history, does not take any medications, and has no drug allergies. Her temperature is 38.9 C (102.0 F). Her lungs are clear to auscultation. Abdomen examination is notable for right upper quadrant tenderness. Pelvic examination reveals mucopurulent drainage and tenderness with cervical motion. She also has adnexal tenderness. Her leukocyte count is 14,000/mm3. Liver function tests are normal. Abdominal imaging is normal. Urine pregnancy test is negative. Which of the following is the appropriate management?

A. Check hepatitis B status
B. Check HIV status
C. Consult surgery for a cholecystectomy
D. Start therapy with ceftriaxone and doxycycline
E. Start therapy with penicillin
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  #2  
Old 12-01-2011
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D

it's PID with Fitz-Hugh-Curtis Syndrome
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Old 12-01-2011
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D. Start therapy with ceftriaxone and doxycycline
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Old 12-01-2011
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D. Start therapy with ceftriaxone and doxycycline
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Old 12-02-2011
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D. Start therapy with ceftriaxone and doxycycline
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Old 12-02-2011
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The correct answer is D. This patient has acute pelvic inflammatory disease. Approximately 5% of women with this syndrome have perihepatitis, or Fitz-Hugh-Curtis syndrome, with right upper quadrant pain and adnexal tenderness in addition to normal imaging results. The most likely pathogen is Neisseria gonorrhoeae. Furthermore, chlamydial coinfection is likely. The patient should be treated with ceftriaxone and doxycycline.
She is also at risk for hepatitis and her status should be checked. This can be done once the acute presentation has been addressed, however (choice A).
This patient should have her HIV status checked (choice B), given her high-risk behavior. The presentation is more consistent with infection with N. gonorrhea, however, and this condition should be treated first.
The laboratory values and imaging that would have revealed cholecystitis are negative. Cholecystectomy (choice C) thus is unlikely to cure this patient.
Treatment with penicillin alone is unlikely to be effective, given that the most likely infection is by N. gonorrhoeae and Chlamydia trachomatis (choice E).
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