A-E Examination: Pelvic Inflammatory Disease

Background and Presenting Complaint

• Miss Chapman has a 2-hour history of severe sudden-onset abdominal pain in the left iliac fossa. The pain does not radiate anywhere and is 9/10 in severity. There are no triggering, relieving, or exacerbating factors. 
• No nausea or vomiting.
• Feeling feverish
• No changes to bowel habits.
• She reports a 5-day history of dysuria and abnormal vaginal discharge.
  • She reports a burning sensation every time she passes urine. She denies any changes to the colour, amount, or frequency of urine. No nocturia or urinary incontinence.
  • She has been having increased amounts of offensive green/yellow vaginal discharge. No associated vulvovaginal itching.
• Her last menstrual period was 1 week ago.
• She usually has regular periods. Her cycle length is 28 days. Her periods last 5 days on average. She denies ever having any problems with her periods, including heavy menstrual bleeding, intermenstrual bleeding, dysmenorrhoea, or post-coital bleeding. Menarche occurred at age 12.
• She is currently sexually active and has multiple sexual partners. She has had the progesterone implant for the past 2 years but admits to not using barrier contraception regularly. 
• She has never been pregnant. She has not had any terminations or miscarriages in the past.

Past Medical History

• Nil Comorbidities

Drug History and Allergies

• Nil
• NKDA

Introduce yourself, confirm the patient’s identify, and gain consent to examine the patient

• Patient confirms full name and DOB
• She gives consent for you to examine her

End of bed inspection

• She appears to be in severe pain

Airways

• Assess the patency of the patient’s airway, ensure that the patient is able to breathe effectively, and there are no airway obstructions.
  • Her airway is patent, as she is able to talk in full sentences 
  • There are no airway obstructions

Breathing

• Inspect for signs of respiratory compromise (e.g. cyanosis, see-saw breathing, use of accessory muscles, nasal flaring, pursed lip breathing, or increased work of breathing)
  • There are no signs of respiratory compromise
• Respiratory rate
  • RR = 14
• O2 sats
  • O2 sats = 99% on RA
• Palpate for tracheal deviation and symmetrical chest expansion
  • Trachea is central and there is symmetrical chest expansion
• Percuss
  • Percussion note is resonant throughout
• Auscultate for reduced breath sounds or added sounds
  • Vesicular breathing bilaterally
  • No added sounds

Circulation

• Inspection (e.g. pale, sweating, clammy)
• Temperature of hands
  • Warm and well-perfused
• CRT
  • 1 seconds
• Heart Rate
  • 104 bpm
• Blood pressure
  • 120/80mmHg
• Insert 2 large bore IV cannulae into each antecubital fossae
  • Take bloods (FBC to check for raised WCC, U&Es and LFTs for baseline, CRP for infection/inflammation, and blood cultures)
• JVP
  • Not raised
• Apex beat
  • Palpable in the left 5th ICS midclavicular line
• Heart sounds
  • Normal
• Fluid status
  • Euvolaemic
• Perform an ECG
  • Sinus Rhythm

Disability

• Level of consciousness (AVPU or GCS if a neurological cause for the patient’s presentation is suspected)
  • Alert
• Pupils
  • Equal and reactive to light
• Blood glucose levels
  • 5.0
• Temperature
  • 38.0°C

Exposure

• Fully expose the patient by removing their clothing whilst preserving their dignity
• Look for any signs of trauma, swelling, bruises, scars, rashes, or signs of a DVT
• Bimanual examination:
  • Cervical motion tenderness
  • No abnormal vaginal discharge present

After completing the initial A-E assessment, reassess! Re-assess the patient to identify any additional clinical changes and effectiveness of any interventions you have performed.

1. What are your differential diagnoses?

• Pelvic Inflammatory Disease (due to severe lower abdominal pain, 5-day history of abnormal vaginal discharge and dysuria, and risk factors for PID including young age, multiple sexual partners, and inconsistent use of barrier contraception)
• Ectopic Pregnancy (It’s important to consider ectopic pregnancy in any woman of childbearing age presenting with abdominal pain)
• Ruptured ovarian cyst (important differential diagnosis in a woman presenting with severe abdominal pain)

2. Given a likely diagnosis of Placenta praevia, how would you manage this patient?

• Inform the obstetrics and gynaecology registrar.
• Do a pregnancy test, urine dip, and STI swabs.
• Insert 1 large bore IV cannula and take bloods (FBC, U&Es, LFTs, CRP, blood cultures, and consider testing for HIV and syphilis).
• Prescribe analgesia and commence empiric antibiotic treatment

3. Please Handover this patient to the obstetrics and gynaecology registrar using the SBAR or equivalent format.

• Hi, my name is Dr. Joe Bloggs and I’m calling from A&E. Can I please confirm who I am speaking to?
• I’ve just examined a patient, who I think has acute pelvic inflammatory disease.
• She is a 22-year-old woman called Lola Chapman.
• She has presented with a 2-hour history of severe sudden-onset abdominal pain in the left iliac fossa, which she rates 9/10 in severity. She also has a 5-day history of dysuria and offensive yellow/green vaginal discharge. There is no associated nausea and vomiting.
• Her last menstrual period was 1 week ago.
• She is sexually active and has multiple sexual partners. She uses the progesterone implant as a form of contraception and admits to inconsistent use of barrier contraception.
• She has no comorbidities or allergies.
• On inspection, she appeared to be in severe pain.
• Her airway was patent.
• Her respiratory rate was 14, O2 sats were 99% in room air, and respiratory examination was unremarkable.
• She was haemodynamically stable. I’ve inserted 1 large bore IV cannula and have taken bloods, including FBC, U&Es, LFTs, CRP, and blood cultures.
• She was alert and pyrexial with a temperature of 38°C. Her BM was normal.
• On bimanual examination, there was cervical motion tenderness. There was no vaginal discharge present.
• Can you please come and see her? In the meantime, is there anything you would like me to do?