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Symptoms Acute /subacuteChronic LocalizedDiffuse SingleMultiple StaticProgressive ConstantIntermittent Single EpisodeRecurrent AbruptGradual SevereMild PainfulNonpainful BiliousNonbilious Sharp/StabbingDull/Vague Problem Characteristics Ill-appearing/ Toxic Well-appearing/ Non-toxic Localized problemSystemic problem AcquiredCongenital New problem Recurrence of old problem Semantic Qualifiers

Illness Script  Predisposing Conditions Age, gender, preceding events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc)  Pathophysiological Insult What is physically happening in the body, organisms involved, etc.  Clinical Manifestations Signs and symptoms Labs and imaging

Predisposing Conditions  Protective factors**  Appropriate condom usage  Other barrier protection  Oral contraceptives** (decreases the risk by up to 7-fold) in face of gonococcal cervicitis  Adolescents/young adults  African American, southeastern rural U.S.  Multiple sexual partners  Vaginal douching  Untreated episode of GC or Chlamydia (10-40%)  Past history of STD or previous PID  Menstruation  IUD

Pathophysiology  Organisms  GC/Chlamydia (50% of cases)  Other  Bacteroides  Peptostreptococcus  Gardnerella vaginalis  H. influenza  Strep species  Enteric GNR  Genital Mycoplasms  **Polymicrobial  Ascending genital tract infection…”salpingo- oophoritis”  Inflammation of:  Endometrium  Fallopian tubes  Ovaries  Peritoneum  **Immature cervix  More ectopy (exposed columnar epithelium)  Further predisposing adolescents to the condition

Clinical Manifestations**  Lower abdominal pain, worse with movement  Vaginal discharge  Irregular bleeding  Fever  Nausea/vomiting  Dyspareunia, dysmenorrhea, dysuria  Physical Exam  Cervical motion tenderness  Adnexal tenderness  Mucopurulent vaginal or cervical discharge

Evaluation**  Detailed history  Abdominal and pelvic exam**  Diagnostic tests** Cervical cultures for Gonorrhea and Chlamydia ○ Nucleic Acid Amplification Test (NAAT) – Urine, vaginal, or endocervical swab Wet prep to rule out concurrent infections (yeast, BV, or trichomoniasis) Pregnancy test UA +/- urine culture, CBC, ESR, CRP Consider pelvic ultrasound  Screen for other STDs** (i.e. HIV, Syphilis)

Hospitalization**

Treatment**

Fitz-Hugh-Curtis Syndrome**  Infection spills into peritoneum and tracks superiorly through the hepato-colic gutter  Inflammation of the hepatic capsule (perihepatitis)  Symptoms Colicky, RUQ abdominal pain Vomiting LFTS typically normal RUQ US often normal…but can show inflammation of the capsule  **Must be considered when evaluating sexually active adolescent with RUQ pain!!

Other Complications**  Tubo-ovarian abscess  Recurrent infection  Chronic abdominal/pelvic pain pain  Ectopic pregnancy Seven-fold increase!!  Infertility Risk increases with delayed diagnosis, younger age of infection, Chlamydial disease, and severe PID

Patient Counseling  Be abstinent for at least 1 week after treatment  Contact sexual partners and encourage their treatment “Expedited partner treatment” – give an advance prescription to patients to assist with treating sexual contacts  Future safe sex practices

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