Case Presenation

Muzna al sawwafi

Emergency medicine/R1

Outlines:

*approaching the case,

*analyzing the data,

*key notes,

*home messages.

Presentaion:

46 yr old lady with lower abd.pain.

*HTN, DM, 3 DAYS H/O BILATRAL LOWER ABD.PAIN, COLICKY, REFERED TO THE BACK AND LEGS, NO NAUSEA, VOMITTED ONCE ,

*NORMAL BOWEL MOTION, NO URINARY SYMPTOMS ,

*HAS VAGIANL DISCHARGES:YELLOW, PURULLENT, SMEELY, LARGE AMOUNT ,

NO VAGINAL ITCHING,

*FIRST TIME,

*AFEBRILE,

*WAS SEEN AT LHC AND RECVIEVED MEDICATIONS, AB? NO IMPROVEMENT ,

*REFERED AS THE PAIN IS MORE SEVER AND TO WORK UP FOR SURGICAL CAUSE(APPENDICITES?), AND VAGINAL DISCHARGES.

*LMP:2WKS AGO, REGUALR, HAS HEAVY PERIOD *13 YR AGO: DIAGNOSTICLAPROSCOPE:PROLIFRATIVE ENDOMEETRIUM, WAS IN F/U AT AL WATYAH HC, NOT ON MEDICATIONS FOR THIS

PROBLEM.(

*HAD BILATRAL TUBE LIGATION 13 YRS AGO ,

*MOTHER OF 9, OLDER IS 29 YRS AND THE YOUNGEST IS 13 YRS, HAD 3 LSCS,

*WAS IN F/U AT PSYCHIATRY 2 YRS AGO FOR SOMATIZATION DISORDER AFTER AN ACCIDENT, CURRENTLY NOT IN F/U OR MEDICATIONS,

CLINICALY:

IN PAIN,PALE, AFEBRILE, P:100, BP:112/82,

CHEST:CLEAR,

ABD:WASEM SCARS, CS SCAR, SOFT, TENDER ON DEEP PALPATION AT THE LOWER ABD.BILATRALY AND SUPRAPUPIC ,

REBOUND TENDRNESS(+)VE

NO ORGANOMEGALY/MASESS,

BS(+)VE,

PV EXAMINATIONS :

SPECULUM EXAM: CLOSED OS, PURULENT DISCHARGES,CERVICAL MUCUSA APPEARED NORMAL,

HVS TAKEN, SENT,

PR EXAMINATIONS:MILD TENDRNESS ANTERIRLY,

URINE DIPSTIK: NILL,

UPT:NEGATIVE,

IMPRESSION?

INVESTIGATIONS:

CBC, U&E, URINALYSIS, URINE MICROSCOPY, CRP:ALL NORMAL,

U/S ABD:VERY DIFFICULT DUE TO INCREASED ADIPOSITY,

BOTH OVARIES NOT VISUALISED, BULKY UTERUS, APPENDIX NOT VISUALISED, PROBE TENDERNESS NOTED AT RIF.

IMPRESSION:

LIMITTED STUDY, APPENDICITIS AND OVARIAN PATHOLOGY CANNOT BE RULED OUT.

ABD.+PELVIS CT:CT ABD WITH IV AND ORAL CONTRAST:

*LIVER, GB, SPLEE, PANCREAS AND BOTH KIDNEYS APPEAR NORMAL.

*DIFFICULT TO DISCERN THE APPENDIX, HOWEVER, NO FREE FLUID NOTED IN THE ABD/PELVIS.NO FAT STRANDING IR INFLAMMATORY CHANGES SEEN.SUBCENTEMETRRIC MESENTERIC LN NOTED ,

BULKY UTERUS, RT.OVARY:NORMAL,LT.OVARY: FOLLICULAR CYST.

CONCLUSION:NORMAL OVARIES. THE APPENDIX IS NOT SEEN BUT NO SIGNS OF APPENDICITIS OR INFLAMMATORY CHANGES.

OBS&GYNE ON CALL REVIWED:

PV: NO CERVICAL TENDRNESS,UTERUS NOT PALAPBLE BIMANUALLY DUE TO PENDIOLUS ABD. ADENEXA FREE,

TVS: POOR PICTURE, UTERUS WITH THIN STREAKS, BOTH OVARIES NORMAL, NO ADNEXAL MASS SEEN,

==========

DISCHARGE FORM GYNE SIDE ,

TRACE HVS AND URINE CULTURE.

SHOULD BE COVERED WITH DOXICYCLINE AND METRONIDAZOLE .

SURGERY ON CALL,

ADMITT THE PT FOR OBSERVATION AND STARTED ON AB. AND ANALGESIA.

NEXT DAY:STII IN PAIN ,

IMPRESSION:

LESS LIKELY TO BE APPENDICITES, DISCHARGED ON CEFUROXIME AND DOXYCYCLINE ,..…

Bacterial vaginosis (BV) is the most common cause of vaginal discharge in women of childbearing age, accounting for 40 to 50 % of cases.

Gardnerella vaginalis, Mycoplasma hominis, Prevotella species, Porphyromonas species, Bacteroides species, anaerobic Peptostreptococcus species, Fusobacterium species, and Atopobium vaginae

Homogeneous, white discharge that smoothly coats the vaginal walls

Vaginal pH greater than 4.5

Positive whiff-amine test

Clue cells on saline wet mount

Vaginal culture has no role in diagnosis because there are no bacteria that are specific for BV .

Gardnerella vaginalis:

the organism is detected in up to 50 to 60 percent of healthy asymptomatic women; thus, its presence alone is not diagnostic of BV.

COMPLICATIONS

Pregnant women with BV are at higher risk of preterm delivery.

There is a causal relationship between BV and endometrial bacterial colonization, plasma-cell endometritis, postpartum fever, post-hysterectomy vaginal cuff cellulitis, and postabortal infection.

BV is a risk factor for HIV acquisition and transmission.

heavy growth of BV-associated microorganisms increased PID risk.

TREATMENT:

Metronidazole,

Clindamycin,

Asymptomatic infection?

*treat asymptomatic BV prior to hysterectomy and before pregnancy termination to prevent postprocedure infection,

*PREGNANT?

Take home messages:

*follow up you pt progress,*BV is the most common cause of vaginitis and

the most common infection encountered in the outpatient gynecologic setting.

*The prognosis for uncomplicated cases of bacterial vaginosis is generally excellent.

*asymtomatic pt with bv ususally need no intervention.