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A 20-year-old sexually active woman presents to the gynaecology outpatient department with bilateral lower abdominal pain for five days, a yellowish vaginal discharge, deep dyspareunia, and fever. Her last menstrual period was three weeks ago. On speculum examination there is mucopurulent cervical discharge; on bimanual examination she has marked cervical motion tenderness and bilateral adnexal tenderness with no masses. Temperature 38.1 degrees Celsius, pulse 96/min, blood pressure 118/74 mmHg.
Questions
a) What is the most likely diagnosis, and what is the single minimum clinical criterion that justifies empirical treatment? (2 marks) Pelvic inflammatory disease (PID). The CDC 2021 minimum criterion is cervical motion tenderness OR uterine tenderness OR adnexal tenderness on bimanual examination in a sexually active young woman with pelvic pain and no other identified cause. She meets this — treat empirically without waiting for NAAT results.
b) Name the classical causative organisms and two other microbial contributors. (2 marks) Classical: Chlamydia trachomatis and Neisseria gonorrhoeae. Other contributors: Mycoplasma genitalium, anaerobes, and bacterial-vaginosis-associated organisms (e.g. Gardnerella, Prevotella) — PID is polymicrobial.
c) List the bedside and laboratory investigations you would order in this patient, with rationale. (2 marks)
- Urine beta-hCG (mandatory — exclude ectopic pregnancy, the lethal mimic).
- Endocervical / vaginal self-taken NAAT for gonorrhoea and chlamydia (and M. genitalium where available); wet mount for WBCs, clue cells, trichomonads.
- FBC, CRP, ESR (specificity-increasing criteria).
- HIV, syphilis and hepatitis serology at the same visit.
- Transvaginal ultrasound if a mass/TOA or ectopic is suspected.
d) State the CDC 2021 outpatient antibiotic regimen with drug, dose, route and duration. (2 marks) Ceftriaxone 500 mg intramuscularly as a single dose (1 g if body weight 150 kg or more) PLUS doxycycline 100 mg orally twice daily for 14 days PLUS metronidazole 500 mg orally twice daily for 14 days. Metronidazole is now routine (added 2021) to cover anaerobes and BV organisms.
e) Describe your public-health and follow-up measures, and list four long-term complications if untreated or recurrent. (2 marks) Treat all sexual partners of the preceding 60 days (expedited partner therapy where permitted); advise abstinence until she and partners complete treatment; rescreen NAAT at 3 months; review at 48 to 72 hours to confirm improvement. Complications: tubal infertility (12 percent after one episode, cumulative), ectopic pregnancy (6 to 10-fold risk), chronic pelvic pain, and tubo-ovarian abscess / Fitz-Hugh-Curtis perihepatitis.