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R5) Abdominal pain, fever, and vaginal discharge
Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.
Learning Outcomes
- Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with abdominal pain and fever.
- Review the DDx considerations in a patient with abdominal pain and fever.
History
A 29-year-old female presents with 5 days of fever, abdominal pain, and lower abdominal pain worsened with intercourse. She also endorses postcoital bleeding and foul-smelling vaginal discharge. The patient is sexually active with two different partners and has a history of previously treated cervicitis gonorrhea and chlamydia (GC/CT).
Physical Exam
BP: 90/62, HR 110, RR 21, Temp 104.0, O2 saturation 99%. General: Patient appears anxious and uncomfortable. Abdomen: tender to palpation in bilateral lower quadrants. Pelvic exam: cervical motion tenderness, purulent cervical discharge.
Labs
WBCs: 22 x 10^9/L (nl 4.5-11 x 109/L); NAAT: Positive for GC/CT; Wet mount: many WBCs/hpf; Pregnancy test: negative
Provisional Diagnosis
Select the Dx you believe is most appropriate
This patient likely has pelvic inflammatory disease or tubo-ovarian abscess considering their risk factors (sexually active with different partners, history of gonorrhea and chlamydia), symptoms and signs (lower abdomen pain, cervical motion tenderness, postcoital bleeding, and purulent vaginal discharge), labs (leukocytosis, NAAT + for GC/CT), and developing sepsis.
Well done. You were correct
Potential Acuity
What is your assessment of the likely acuity for this patient?
Well done. You were correct
The patient requires urgent workup considering their sepsis. Untreated PID can lead to sequelae like infertility, chronic pelvic pain, and ectopic pregnancy.
First Imaging Study
What is the first imaging study you will order?
The transvaginal ultrasound is an appropriate initial, non-radiating imaging modality to evaluate for PID or TOA.
Well done. You were correct
Pertinent Imaging Observations
Click on the links below to view images from the study, and assess these key findings as best you can.
Transvaginal ultrasound
There is an abnormal lesion.
There is a lesion filled with debris and fluid in the cul-de-sac with an irregular, thickened wall.
The lesion exhibits dependent debris.
The dependent debris suggests that this lesion is an abscess.
View the full study if you'd like to take a look yourself.
Second Imaging Study
What is the next imaging study you will order?
A CT scan of the abdomen and pelvis with IV contrast is the most appropriate test considering the patient needs urgent workup and is not pregnant. An MRI would be preferable had the patient been hemodynamically stable as it would limit radiation.
Well done. You were correct
Pertinent Imaging Observations
Click on the links below to view images from the study, and assess these key findings as best you can.
CT with IV Contrast
There are pelvic abscesses.
There is a large and extensive pelvic abscess. There are also bilateral tubo-ovarian abscesses.
View the full study if you'd like to like a look yourself
Third Imaging Study
What is the next imaging study you will order?
No further imaging is required as the diagnosis is confirmed with CT.
What is your Diagnosis now that you have seen the imaging results?
This patient has both pelvic and tubo-ovarian abscesses.
Current Acuity
Initially, you selected and we suggested acuity.
Has your concern for this patient changed?
This patient with sepsis requires urgent management.
Assessment and Plan
Please provide your assessment and plan for this patient
This is a 29-year-old female presenting with pelvic and tubo-ovarian abscesses with resultant sepsis. Therefore, we will consult OBGYN for consideration for surgical exploration or need for image-guided drainage. Considering that the patient is hemodynamically unstable from sepsis, they will likely require surgical intervention. In the interim, the patient should receive IV fluids and IV antibiotics. The antibiotic regimen will then be narrowed based on blood culture or abscess drainage culture findings.
Lessons Learned:
- A tubo-ovarian abscess represents an infection involving the fallopian tube or ovary.
- A ruptured abscess should be suspected in a patient with sepsis.
- A TVUS can reveal a fluid filled structure mass with dependent layering. CT scan can demonstrate a mass with high attenuating fluid, a thick, enhancing abscess wall, and sometimes air/fluid or fluid/fluid levels. Similarly, on MRI, it would appear as a thick-walled fluid filled mass with hypointense contents on T1 and hyperintense contents on T2.
Socioeconomic Factors:
- PID and TOA have similar risk factors. These include a history of GC/CL, multiple sexual partners, and a prior episode of PID.
That's the end of the module! Once you've reviewed the video(s), you can click here for another case challenge.
Contributors:
Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh, MS - Coordinator
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