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Abstract: The patient was in a young sexually active period, but had insufficient knowledge of sexual hygiene, leading to frequent sex, menstrual sex and other undesirable sexual behaviors, which led to abnormal leucorrhea, abdominal pain and other symptoms, but did not pay attention to it, and only sought medical attention when the abdominal pain was obvious. The examination of routine blood leukocytes and ultrasensitive C-reactive protein were significantly elevated, and the diagnosis of pelvic inflammatory disease was made, and after giving combined drug treatment, all indicators had The patient’s abdominal pain was relieved.
Basic information】Female, 24 years old
Type of disease】Pelvic inflammatory disease
Hospital】Jiangbin Hospital of Guangxi Zhuang Autonomous Region
Time of consultation】June 2022
Treatment plan】Medication (cefotaxime sodium for injection + 0.9% sodium chloride solution + metronidazole injection + diazotide suppository)
Treatment period】Hospitalization for 10 days, followed by hospital review in 1 week
Treatment effect】Temperature returned to normal, white blood cell decreased, abdominal pain disappeared, treatment effective
I. Initial consultation
The patient reported that she usually stayed up late, smoked and drank occasionally, and seldom exercised, and denied a history of pregnancy. In April this year, she met a new boyfriend, and after the two of them lived together, the frequency of sexual intercourse increased, usually about 10 times a week. In early May, the patient had a leucorrhea abnormality, which improved after vaginal douche treatment in a small clinic (details unknown). The last menstrual period was on May 22, 2022, and the period cleared in 7 days. During the period, the patient had sexual intercourse 2 times. After disinfection, the doctor performed a gynecological examination. There was much vaginal discharge, painful lifting of the cervix, flushing of the cervical orifice covered with purulent discharge, and pressure pain in the uterus and bilateral adnexal areas, which led to the diagnosis of pelvic inflammatory disease and hospitalization.
II. Treatment history
On admission, the patient’s vital signs were normal and there was no obvious fever. She was given complete relevant examinations, including routine blood results of leukocytes 13.56×10^9/L, ultrasensitive C-reactive protein 25.81 mg/L, white belt examination results of cleanliness degree IV, Gardnerella (+), blood HCG (-), and ultrasound results of uterus and bilateral adnexa with no obvious abnormalities. The patient asked the doctor about the cause of abdominal pain. After detailed questioning, the doctor analyzed that the diagnosis of pelvic inflammatory disease was clear from the current patient’s medical history, clinical signs and laboratory results, and the patient’s abdominal pain was caused by pelvic inflammatory infection and not other diseases such as ectopic pregnancy or appendicitis. The pelvic inflammatory disease is very much related to the patient’s recent bad habits such as frequent sex, staying up late, smoking and drinking, and sex during menstruation, and the patient is advised to actively cooperate with the treatment. After admission, she was given cefotaxime sodium for injection + 0.9% sodium chloride solution and metronidazole injection for anti-inflammatory treatment, as well as diazotide pessary for vaginal plugging for bacterial vaginitis.
III. Treatment effect
After 5 days of treatment, the patient’s vital signs were normal, abdominal pain was significantly reduced, and the results of routine blood tests were 9.83×10^9/L for leukocytes and 11.23 mg/L for ultrasensitive C-reactive protein, indicating that the treatment plan was effective, and the medication was continued, and the vaginal plug was discontinued for 7 days. After 10 days of treatment, the routine blood results showed leukocytes 7.27×10^9/L, ultrasensitive C-reactive protein 5.36mg/L, white belt examination results cleanliness degree III, Gardnerella (-), the patient had no fever, no abdominal pain, lower abdominal cramps disappeared, no obvious pressure pain in the uterus and adnexal area on gynecological examination, and was discharged from the hospital. The patient was asked to come to the hospital for review 1 week after discharge.
IV. Notes
We are glad that the patient’s symptoms have improved after treatment, but we still need to remind the patient to pay attention to some matters in daily life: 1.
1. As the patient is young and sexually active, it is recommended that the patient pay more attention to sexual hygiene, understand sexual knowledge and never choose to have sex during menstruation.
2, because the patient’s vaginitis medication is only one course of treatment and not completely cured, it is recommended that the patient continue to use the medication for 1 week after discharge from the hospital and then review the leucorrhoea examination in the outpatient clinic.
3. During the treatment period, patients are advised to pay attention to improving their body immunity, not to have sex, to do physical exercises such as jogging, ball games and yoga appropriately, and to avoid staying up late and smoking and drinking.
4. The patient belongs to a young woman, who is not sufficiently aware of the danger of pelvic inflammatory disease and has certain psychological fears. The doctor gives a detailed explanation and guidance, which is beneficial to the patient’s physical and mental health.
V. Personal insight
Pelvic inflammatory disease occurs mostly in young women in their 20s, but rarely in non-sexual or older women, because pelvic inflammatory disease infection spreads upward from vaginitis, so not paying attention to sexual hygiene during the sexually active period can easily lead to morbidity. The patient should seek medical attention as soon as possible after the symptoms of pelvic inflammatory disease infection appear, which can be cured quickly by giving adequate, standardized and symptomatic antibiotic treatment. If not treated in time or with the wrong medication, it is easy to extend into chronic pelvic disease, leading to long-term abdominal pain and infertility, so it is important to actively treat the symptoms as early as possible.