Both ultrasonography and computed tomography demonstrate normal results. The next best step in treatment is to conduct a pelvic exam, which demonstrated mild cervical motion tenderness. Consultation with a gynecologist is advised due to the patient’s high white blood cell count.
Pelvic inflammatory disease (PID) should always be included in the differential diagnosis for lower abdominal pain in a female patient, especially when there is no other obvious cause. PID often is missed or diagnosed late for a variety of reasons, including no vaginal discharge, no new sexual partner, not sexually active, older age, minimal tenderness, normal laboratory assessment, and no fever. However, PID is a common condition, especially in younger women, and is associated with significant short- and long-term morbidity and mortality.
Approximately 15% of PID cases do not result from a sexually transmitted infection. Fever is present in approximately 30% of patients, and laboratory assessment is often normal. Aside from screening for sexually transmitted infections, the next best step in management is to obtain a C-reactive protein (CRP) level. Advanced imaging is often indicated, primarily to rule out other conditions such as appendicitis or ovarian cyst; however, if imaging is negative, clinical suspicion for PID should rise sharply. Causes of PID can include anaerobes, Streptococcus species, and Staphylococcus aureus, but the most common causative organism is Chlamydia trachomatis.
Remember to also consider chlamydia in a female patient presenting with right upper quadrant pain and an otherwise negative clinical presentation, even if no pelvic symptoms are present and the pain is pleuritic. Fitz-Hugh-Curtis syndrome is often missed because isolated right upper quadrant pain may be present without vaginal or pelvic symptoms, a presentation similar to that seen in a patient with pyelonephritis and no dysuria. Assessment of CRP level and presence of chlamydia should always be considered with such presentation.
For the patient in this case, a gynecologic examination found no cervical motion tenderness, and the patient was discharged. She then returned to the ED when her temperature spiked to 103.4°F, and she was admitted to the ED for a nongynecologic cause of fever and abdominal pain. Additional laboratory testing found a normal erythrocyte sedimentation rate; however, CRP was elevated at 85 mg/L. Examination was negative for gonorrhea but positive for chlamydia. The patient was transferred back to the gynecology service.
Pregerson DB. Emergency Medicine 1-Minute Consult Pocketbook. Emresource.org; 2017;5.