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Abstract: The patient in this case had chronic adnexitis for 3 years and developed lower abdominal pain, anal cramps and fever after intercourse 2 days ago, and was diagnosed with acute ovarian inflammation after examination, then treated with anti-inflammatory therapy + proprietary Chinese medicine, the patient’s body temperature returned to normal, no lower abdominal pain, and continued to take oral anti-inflammatory medication for consolidation after discharge, and the patient’s discomfort disappeared after 7 days of follow-up. The patient’s discomfort disappeared after 7 days of follow-up. Annexitis, including ovarianitis, can easily lead to recurrence and spread of inflammation if left untreated or unattended in life.
Basic information】Female, 37 years old
Disease Type】Acute Ovarian Inflammation
Hospital】Guangzhou Huadu District People’s Hospital
Date of consultation】June 2021
Treatment plan】Medication (cefuroxime sodium injection, metronidazole injection, glucose injection, compound sodium chloride injection, compound amino acid injection, cefuroxime ester tablet, adamantine capsule)
[Treatment period] 13 days of inpatient treatment, follow-up after 7 days
Treatment effect】No discomfort, patient cured
I. Initial consultation
On June 6, 2021, Ms. Liu visited the clinic accompanied by her family due to lower abdominal pain, anal cramps and fever for 2 days. G3P2, i.e. 3 pregnancies and 2 deliveries, including 2 full-term normal deliveries and 1 abortion, had chronic adnexitis for 3 years. Last menstrual period on May 20, 2021 with normal amount, 2 days ago after intercourse, she felt pain in the lower abdomen and gradually worsened, accompanied by localized anal drop, with elevated body temperature, no cough and sputum, sore throat, etc. T: 38.9℃, P: 92 times/min, R: 22 times/min, BP: 120/82mmHg, no abnormal heart and lung auscultation, flat abdomen, significant lower abdomen There was significant pressure pain and rebound pain in the lower abdomen. Gynecological examination: vaginal discharge was increased, yellow in color but no bloody discharge, several nuchal cysts were seen in the local normal size of the cervix, painful cervical lifting (+) and tenderness in the posterior vaginal vault (+). The body of the uterus is normal in size, with normal activity and no significant pressure pain. The left adnexal area was thickened and a 5cm x 5cm x 4.8cm mass was palpable with significant tenderness and normal activity, while no abnormality was palpable in the right adnexal area. The right adnexal area was not abnormal. The fallopian tubes were slightly thickened with localized pressure pain. Vaginal color ultrasonography: multiple liquid dark areas were seen locally in the cervix, with a maximum of 7mm×6mm. The uterus was 6.5cm×5.5cm×5cm in size, with uniform myometrial echogenicity and a 9mm thick endometrium. Ultrasound examination of the left fallopian tube did not show fluid accumulation and obvious thickening, and fluid accumulation in the rectal trap of the uterus 3cm×3cm×4cm. Urine pregnancy test (-), blood count: leukocyte count was 10.37×10＾9/L, neutrophil was 7.92×10＾9/L. Biochemical examination: k+3.15mmoI/L, other biochemical results were normal, preliminary diagnosis of acute ovarian inflammation.
II. Treatment history
After the completion of laboratory tests after hospitalization, cefuroxime sodium and metronidazole injection were administered intravenously. Due to the patient’s poor condition, poor appetite and low potassium, she was given 5% glucose injection, compound sodium chloride injection and compound amino acid injection for intravenous rehydration. On the 4th day of hospitalization, the body temperature returned to normal, but the lower abdomen was still painful, so anti-inflammatory treatment was continued, and intravenous rehydration was stopped because the patient had resumed normal diet. On the 9th day of hospitalization, the general condition was good, the body temperature was normal, there was no pain in the lower abdomen, no anal swelling, and not much vaginal discharge, so the intravenous antibiotics were stopped and the oral antibiotic cefuroxime tablets and the Chinese patent medicine Vajra capsule were continued to be taken orally.
III. Treatment effect
After 13 days of clinical anti-inflammatory treatment and intravenous rehydration, the patient’s body temperature was normal, there was no lower abdominal pain, no anal swelling, and not much vaginal discharge. Gynecological examination: no painful lifting of the cervix, no tenderness in the posterior vault, normal size of the uterus, normal activity, no pressure pain, no significant thickening in the left adnexal area, normal size of the left ovary, normal activity, no pressure pain, no pressure pain in the left fallopian tube. Vaginal ultrasound examination: multiple local liquid dark areas in the cervix, normal size of the uterus, left ovary 4cm×3cm×2cm, no obvious blood flow signal, no effusion in the rectal trap of the uterus, discharged on June 19, 2021. The patient was advised to drink more water and take oral vajra capsule for 7 days after discharge, and the patient’s discomfort disappeared after 7 days of follow-up.
IV. Precautions
After the patient was discharged from the hospital, it is recommended to take proper rest, pay attention to a light diet and abstain from spicy and sour food. She should not have intercourse for half a month, pay attention to intercourse and menstrual hygiene in the future, stop having intercourse during menstruation, strengthen vulva care in daily life, and change underwear regularly. If you experience pain in the lower abdomen and abnormal vaginal discharge again, you should go to the hospital in time. In fact, I often see similar female patients in the clinic. Although this patient was cured and I am happy for her, I still want to remind patients with gynecological inflammation that they must be treated in time and not ignore the harm caused by the disease.
V. Personal insight
This patient was cured after treatment, and when she came to the hospital for follow-up, I also gave her relevant information and follow-up questions to pay attention to. As a common gynecological disease, ovarian inflammation has many causes, and some patients, like the patient in this case, have a recurrence of inflammation. Therefore, not only patients with previous gynecological inflammation, but also healthy women should pay attention to hygiene and vulva care in their daily life in order to effectively avoid recurrence.