PATIENT PROFILE

Name: Address: Gender: Age: Status: Religion: Nationality: Occupation: Mrs. Lock DMV Bagong Bayan Female 19 years old Live in Catholic Filipino Housewife

ADMITTING PROFILE
Attending Physician: Date: Time of admission: Room type & #: Chief complaint: Dra. Marysol Cerda June 25, 2011 11:00 am Private/ 304 Lower quadrant abdominal pain

PHYSICAL EXAMINATION
GENERAL APPEARANCE: SKIN: Pinkish, skin turgor (2 sec) Hair is not that neat. Postural alteration Facial grimace

HEAD AND NECK: No nodules or tumors

THORAX AND LUNGS: y Inspection: Symmetrical Chest configuration: 1:2 Without nodules Auscultation: Normal lung sound: Vesicular, bronchovesicular, & bronchial Absent adventitious sounds Palpation: Tactile fremitus: normal distribution of vibration Lung excursion: normal, expansion test- symmetrical thumbs (3-5 cm) Percussion: Resonant

BREAST: y y No nodules or lumps present. Left is slightly larger than the other.

CARDIOVASCULAR SYSTEM: y y y Point of maximal impulse: 90 beats per minute Blood pressure: 100/60 Auscultation: Audible heart sound

ABDOMEN: Inspection Flat Auscultation Borborygmi Palpation Percussion

Right upper quadrant Left upper quadrant Right lower quadrant Left lower quadrant

Tympany Globular Firm Firm

VAGINAL DISCHARGE:

Scanty purulent discharge

ASSESSMENT USING GORDONS 11 TYPOLOGY

HEALTH PERCEPTION/HEALTH MANAGEMENT -Is not aware and does not understand medical diagnosis -Does not give thorough history of illnesses and surgeries NUTRITIONAL/METABOLIC -Usual eating pattern: 3 meals a day ELIMINATION -Decreased urinary frequency and amount. -Last bowel movement yesterday: formed, state was normal. ACTIVITY/EXERCISE -No musculoskeletal impairment SLEEP/REST PATTERN -Had impaired sleeping pattern because of painful perception. COGNITIVE/PERCEPTUAL -No sensory deficits -Pupils 3mm, equal, brisk reaction -Oriented to time, place and person -Responsive, but fatigued -Respond appropriately to verbal and physical stimuli -Reports pain in the lower abdomen ROLE/RELATIONSHIPS -Lives with husband and 2 year-old child -States good relationship with the family. SELF PERCEPTION/ SELF CONCEPT -hair not well fixed says hindi ako masyadong makapagsuklay sa sobrang sakit ng tiyan ko. COPING/STRESS -Postural pressure in the abdomen. VALUE/BELIEF -Catholic -No special practices

SEXUALITY REPRODUCTIVE -Had sexual intercourse twice a month using calendar method.

MATERNAL HISTORY Obstetric scoring: G2T1P1A1L1M0 y y Imminent abortion during the 4th month of pregnancy. The patient had recently undergone dilatation and curettage.

DIAGNOSTIC TEST

ULTRASOUND

Patients with pelvic inflammatory disease typically present with pelvic pain, a purulent vaginal discharge, and pelvic tenderness, with the onset of symptoms often after menstruation. CLINICAL SIGNIFICANCE: Ultrasound may reveal a dilated tube, better visualized if there is purulent cul-de-sac fluid present .Typically; motion of the vaginal transducer reveals an immobile mass that is exquisitely tender.

Name: SAN BUENAVENTURA GERLIE Date: June 20, 2011 Pertinent data: (+) fever, Post D/C one month ago I. UTERUS: 4.7 X 4.8 X 4.1 cm Retroverted ABNORMALITIES NOTED: Transvaginal scan shows normal sized anteverted uterus with no myometrial lesion. II. ENDOMETRIUM 0.8 cm hypoechoic/ isoechoic/ hyperechoic/ triple line ABNORMALITIES NOTED: Slightly thickened endometrium with dilated parametrial vessels. III. Adnenae

RO: 3.5 X 2.9 X 2.9 cm Lateral/ Posterior-Lateral/Posterior Dominant follicle: The right ovary is converted into a cystic structure, unilocular, thin walled (0-2), anechoic, suggestive of a follicular cyst. LO: 2.0 X 1.6 X 1.2 CM Lateral/ Posterior-lateral/ posterior The left ovary is normal in sized and echoetexture. Lateral to left ovary is a tubulocystic structure, thick walled, anechoic, with incomplete septations measuring 1.7 x 0.6 x 0.7 cm suggestive of metritis with hydrosalpinx to consider PID. IV. CERVIX: 2.0 X 2.3 X 2.9 No free fluid in cul de sac

IMPRESSION: Normal sized retroverted uterus slightly thickened endometrium follicular cyst, right ovary normal left ovary metritis with hydrosalpinx to consider PID.

CLINICAL DISCUSSION
PELVIC INFLAMMATORY DISEASE It is an inflammatory condition of pelvic cavity that may begin with cervicitis, and may involve the uterus (endometritis), fallopian tube (salpingitis), ovaries (oophoritis), pelvic peritoneum, or pelvic vascular system. Infection may be acute, subacute, recurrent, or chronic, and localized or widespread.

CAUSES: 1. Microorganisms Neisseria gonorrhoeae Clamydia trachomatis Clostridium perfringes Actinomyces Mycoplasma Streptococci Staphylococci Coliform bactreria 2. Breakage in sterility in some medical procedures: IUD insertion, Cesarean section, Dilatation and curettage and suctioning for the purpose of abortion, or removal of polyps or unexpelled placental fragments. RISK FACTORS:
y y y y

Are under 25 years of age and are having sex Have had STI. Have more than 1 sex partner Douche. Douching can push bacteria into the pelvic organs and cause infection. It can also hide the signs of an infection. Have an intrauterine device (IUD)

SIGNS AND SYMPTOMS: 1. Lower abdominal pain -description: dull 2. Purulent vaginal discharge 3. Fever 4. Painful urination 5. Painful sex 6. Irregular menstruation 7. Intense tenderness may be noted on palpation of the uterus or movement of cervix (cervical movement tenderness)

PATHOPHYSIOLOGY

Entry of microorganism to the vaginal orifice may be due to unsafe sexual intercourse, unsterile medical procedures.
Vasoconstriction due to effect of thromboxane

Colonization of microorganism in the passageway (cervix).

Vasodilation Hyperemia (leukocyte invasion in the site of damage)

Inflammatory process in the lower part of the pelvis in response to burrowing of microorganism.

Increased permeability Extravasations Leukocyte invasion (phagocytosis) Accumulated fluid (exudates and abscess formation) Pressure on the nerve (Pain)

Ascending infection will cause inflammation of upper pelvic organ, uterus (endometritis), fallopian tube (salpingitis) and ovary reach the liver Further infection can (oophoritis). and diaphragm which will cause hepatic infection and diaphragmatic infection.

Infection will spread in the circulation.

Further infection affecting other systems and tissue degeneration.

Death

DISCHARGE PLAN:
HEALTH TEACHING: 1. 2. 3. 4. 5. Instruct the patient to immediately report fever. Teach the patient the proper way of washing the perineal area. Inform about the medications. Encourage the patient to comply with checkups. Encourage the patient to eat nutritious foods.

Canossa College College of Nursing

CASE PRESENTATION AT CERDA LYING IN AND MATERNITY CLINIC

PELVIC INFLAMMATORY DISEASE

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