The primary diagnosis of Sonya Phillips is Tubo-ovarian abscess secondary to PID. Below is an ihuman case study on Sonya Phillips.
iHuman Management Plan Template: Sonya Phillips
23yo, 5’9”, 121lb(55kg)
CC: Abdominal pain/LEFT pelvic pain
Primary Diagnosis: Tubo-ovarian abscess secondary to PID **possible rupture: Clinical findings of tubo-ovarian abscess rupture include hypotension, tachycardia, tachypnea, acidosis, and acute peritoneal signs (Beigi, 2018). Classic presentation of a tubo-ovarian abscess includes abdominal pain, fever, leukocytosis, , vaginal discharge, and fever/chills (Kairys & Roepke, 2018).
Status/Condition: Guarded
Code Status: Full
Lower abdominal pain x 5 days (suprapubic area), radiates to LLQ into pelvis. Diaphoresis, chills, nauseated, dizzy. Pain = 8/10; Achy in abdomen, now into pelvis, deep inside
She thought it was a bladder infection so started drinking cranberry juice; now moved lower into pelvis and getting worse
Standing and working makes it worse, now any movement and walking around makes it worse. Nothing makes it better. Pain when resting too. Was dull and achy, now intense boring pain on L side. Pain = 8/9. Constant.
Vaginal discharge +, smells strong and smelly. “nasty”, started around time the and pain started, started after period ended. HX of chlamydia a few years ago
Regular periods, birth control pills. No bleeding in between Had HPV immunization, all others UTD
Birth control pills—Tri-Cyclen OTC—nothing
FMH: Dad 53, type 2DM, Mom is healthy
SH: Drinks socially 2-3 times a week, 4-6 drinks each time, doesn’t always use condoms; 3 ongoing relationships with 3 guys, plus a few one night stands
Allergies:
NKA
Admit to Unit: Surgical ICU
Activity Level: Up as tolerated
Diet: NPO pending surgical evaluation
IVF (if ordered, include type and rate ):
NS IVF bolus of 30mL/kg due to probable sepsis/SIRS as evidenced by elevated WBC count, hypotension, elevated HR, fever
Followed by NS @100mL/hr
Critical Drips (If ordered, include type and rate. Do not defer to ICU Protocol): None at this time; pressors on hold for SBP < 70
Respiratory: N/A
Medications: (include ALL, tx of primary condition, underlying conditions, pain, comfort need setc. dose and route)
Cefotetan 2g IV Q12 hours (Woo, 2018) AND
Doxycycline 100mg IVQ12 hours (Beigi,2018)
Hold TriCyclen
Morphine 1mg Q4hours PRN for severe pelvic pain Acetaminophen 650mg Q6 hours for fever Nursing Orders:
STRICT I/O
Q4VS minimally
Keep NPO for GYN evaluation of possible rupture Cooling blanket if temp > 102
Obtain blood culture prior to initiating abx
Follow Up Lab tests: CBC daily to ensure WBC coming down. Draw blood cultures. Check ESR.
Diagnostic testing (CXR,US, 2D Echo, etc…):
CBC:
WBC—22.6k
Neutrophils 89%, 8% band cells; neutrophilia with left shift UA neg. (r/o UTI)
Urine pregnancy neg.
Pelvic ultrasound—tubo-ovarian abscess; myosalpinx, ovarian tissue seen inferior to pyosalpinx and surrounded by complex appearing fluid consistent with ovarian abscess
Abd ultrasound to r/o appendicitis
Consults:
GYN consult for possible surgical excession/ transcutatneous/transvaginal aspiration
Patient Education and Health Promotion (address age appropriate patient education if applicable):
Patient education should focus on how the patient can help to prevent this from occurring again through safe sex practices. The patient likely developed her tubo-ovarian abscess from contracting a sexually transmitted infection which led to her developing pelvic inflammatory disease. STIs often present with no symptoms at all and the patient may not have known, which is why it is likely that she developed PID without realizing it. We should educate regarding the S/S of PID and how safe sex can help prevent her from developing it again (Lee, 2017).
Discharge planning and required follow-up care: Discharge to home in 3-4 days pending clinical improvement with prescription for doxycycline 100mg BID for 14 days. Follow up with GYN in one week.
References (minimum of 3, timely references, that prove this plan follows current standard of care).
Beigi, R. H. (2018). Management and complications of tubo-ovarian abscess. Retrieved fromhttps://www.uptodate.com/contents/management-and-complications-of-tubo-ovarian- abscess#H1250624449
Kairys, N., Roepke, C. (2018). Abscess, tubo-ovarian. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK448125/
Lee, L. (2017). Pelvicinflammatory disease. Journal of the AmericanAcademy of PAs, 30(2), 47- 48. doi:10.1097/01.JAA.0000511799.14244.57
Woo, J. (2018). Chapter 18: Gynecologic disorders. In M. A. Papadakis, S. J. McPhee,& M. W. Rabow (Eds.),Current medicaldiagnosis & treatment(771-804). New York, NY: McGraw Hill
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