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Abstract: Pelvic fluid is divided into exudate and leaky fluid, of which exudate is mostly due to pelvic inflammation, and auricular fistula may be caused by internal bleeding due to rupture of the corpus luteum or ectopic pregnancy. After clinical anti-inflammatory treatment, western medicine and physical therapy, the patient was cured.
Basic information】Female, 30 years old
Disease Type】Pelvic effusion, pelvic inflammatory disease
Hospital】Guangzhou Huadu District People’s Hospital
Date of consultation】June 2019
Treatment plan】Medication (sodium penicillin for injection + metronidazole injection + vincristine capsule) + far infrared radiation
Treatment Period】22 days of hospitalization
Treatment effect] The patient’s condition improved effectively
I. Initial consultation
The patient, Ms. Wang, was diagnosed with pelvic inflammatory disease one year ago after an abortion, and the abdominal pain was relieved by oral gynecological Qianjin tablets, but she was not seen again. Recurrence. On admission, T: 36℃, P: 78 times/min, R: 20 times/min, Bp: 100/60mmHg, general condition is still good, no abnormality on cardiopulmonary auscultation, no pressure pain in the upper abdomen, no palpation of liver and spleen, pressure pain below the umbilicus in the lower abdomen (+), no local erythema on gynecological examination, vaginal patency, small amount of yellow discharge without obvious odor, localized cervical erosion of degree I, obvious painful cervical lifting, uterus The uterus was in retroflexion and retroversion, with pressure pain (＋) and fair activity, and bilateral adnexal areas with thickening and pressure pain (＋). Vaginal ultrasound examination showed pelvic effusion of 2.8 cm, small nodules in the myometrium, no tubal effusion, no abnormal blood tests, preliminary diagnosis of pelvic inflammatory disease and pelvic effusion.
II. Treatment history
The patient had a long medical history, and the combination of Chinese and Western medicine was considered. Firstly, the penicillin was negative by skin test, so the combination of penicillin sodium for injection and metronidazole injection was administered intravenously, and the lower abdominal pain was relieved on the ninth day of administration. At this time, the gynecological examination of the cervix did not lift pain, and the pressure pain in the uterus and adnexal area improved significantly. The patient was also instructed to pay attention to rest, strengthen nutrition, not to eat spicy and acidic food and not to drink alcohol. At the same time, physical therapy, i.e. far-infrared radiation to the lower abdomen, promoted local blood circulation, accelerated local metabolism, so that the inflammation was absorbed as soon as possible. After discontinuing the western medicine, the patient was instructed to take oral vajra vine capsule for 12 consecutive days, and the clinical symptoms gradually disappeared.
III. Treatment effect
After clinical active anti-inflammatory treatment, combined with physiotherapy and Chinese medicine oral medication, clinical symptoms basically disappeared, the patient had no lower abdominal pain, vaginal discharge was not much, and fatigue felt significantly better before. After gynecological examination, there was no pressure pain in the uterus and adnexal area, but there was thickening in both adnexal areas, and the pelvic fluid was completely absorbed by ultrasound examination. She was clinically cured and was discharged at 22 days of hospitalization.
IV. Notes
We are glad that the patient’s symptoms were cured after treatment. We suggest that the patient needs to strengthen local care of vulva in daily life to avoid retrograde infection of pathogenic bacteria causing recurrence of pelvic inflammatory disease, and pay attention to sexual hygiene and diet to avoid eating spicy and acidic stimulating foods, and do a good job in contraception to avoid unwanted pregnancy and abortion leading to recurrence of pelvic inflammatory disease. The first thing you should do is to seek medical advice and use medication under the guidance of your doctor to avoid acute attacks of chronic pelvic inflammatory disease.
V. Personal insight
Pelvic inflammatory disease is one of the common inflammatory diseases in gynecology and usually occurs after childbirth, after induction of labor, after abortion or during menstruation without paying attention to hygiene, as well as sexual life without paying attention to hygiene. Therefore, for the acute phase of pelvic inflammatory disease must be medicated, enough medication for a long enough time to achieve a complete cure, to avoid leading to chronic pelvic inflammatory disease and recurrent lower abdominal pain. The patient in this case may have been treated incompletely the first time she had pelvic inflammatory disease, which led to chronic pelvic inflammatory disease and the formation of pelvic effusion. Through this case, we learned that it is important to systematically and regularly treat pelvic inflammatory disease to avoid triggering other discomforts.