Voiceover: Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer.
So, if you're ready, let's jump right in.
Margaret Fitzgerald: A 24-year-old adult assigned female at birth presents to your practice with the chief complaint of bilateral lower abdominal pain the past 3 days worsening over this timeframe. She describes the pain as a heavy, pressure-like feeling and is accompanied by intermittent fever, mild dysuria, yellow vaginal discharge as well as nausea without vomiting, and has a markedly decreased appetite.
Additional history of presenting illness includes recent LMP ending around 3 days ago with normal timing and normal flow. She is sexually active with two male partners and describes that last episode of coitus 6 days ago was painful with deep pelvic discomfort. Physical exam reveals a temp of 100.4 degrees Fahrenheit, the rest of her vital signs are within normal limits.
Mild lower abdominal discomfort to light and deep palpation without rebound, yellow vaginal discharge, and cervical motion tenderness without a palpable pelvic mass. The clinical presentation is most consistent with:
A: Acute appendicitis.
B: Pelvic inflammatory disease.
C: Ovarian cyst.
D: Ectopic pregnancy.
And the correct answer is B: Pelvic inflammatory disease. Where should we start with this question? Figure out first what kind of a question it is. And we're being given a clinical presentation that's actually fairly detailed and being asked what most likely is causing this.
This is, of course, a diagnosis question. Let's take a look at some background information about pelvic inflammatory disease, more commonly simply referred to as PID. PID is an upper reproductive tract infection found in females and consists of endometritis, salpingitis, and oophoritis. In other words this infection involves lining of the uterus-that's the endometritis.
The fallopian tubes, the salpingitis; and the ovaries, the oophoritis, and the surrounding structures. About 60% of the time, the problematic pathogen for this infection is sexually acquired and it's most often seen in female birth gender-assigned individuals, 25 years or younger who are sexually active with more than one person, or have a partner who has more than one partner.
The most common pathogens contributing to the development of PID, include those often noted STI organisms such as Chlamydia trachomatis and Neisseria gonorrhea. At the same time, about 40% of these infections are polymicrobial and other causative organisms can include Haemophilus influenzae, assorted streptococci species, and select anaerobes, as well as some other STI organisms we're learning more about, like Ureaplasma urealyticum and Mycoplasma genitalium.
As you'll notice, many of these organisms often cause lower reproductive tract infections and the lower reproductive tract infections, examples of those would be cervicitis, vaginitis, and urethritis. With PID, its clinical presentation is usually with a chief complaint of lower abdominal pain, usually bilaterally-sometimes can be more unilaterally and sometimes even if it's bilateral, the woman will say one side hurts more than the other. Generally present for a number of days and worsening over that time period.
And that's exactly what we have here. Other signs and symptoms can include abnormal vaginal discharge, dyspareunia, which she reports with last coitus, fever, GI upset, and/or abnormal vaginal bleeding. An adnexal mass can be palpable when tubo-ovarian abscess is present, but it's most often missed on physical exam. And tubo-ovarian abscess is not always found with PID but the eendometritis and salpingitis is. PID should be considered when a woman presents with new-onset lower abdominal or pelvic pain, coupled with at least one of the following clinical findings: vertical motion tenderness, uterine tenderness, and/or adnexal tenderness.
With this as background information, let's take a look at the question again, the proposed answers, and responses and rationales. One major issue here, when you're coming up with a diagnosis, you always need to know what the typical presentation of the disease is; 24-year-old adult assigned female at birth presents to your practice with the chief complaint of bilateral lower abdominal pain for the past 3 days, worsening over this timeframe.
She describes the pain as a heavy, pressure-like feeling and is accompanied by intermittent fever, mild dysuria, yellow vaginal discharge, as well as nausea without vomiting. She's tolerating fluids well and has a marked decreased appetite. Additional history of present illness include a recent LMP ending about 3 days ago with normal timing and normal flow. She is sexually active with two male partners and describes her last episode of coitus being 6 days ago painful to deep pelvic discomfort.
The physical exam reveals a temp of 100.4 degrees Fahrenheit, but rest of vital signs within normal limits. Mild lower abdominal discomfort to light and deep palpation without rebound, yellow vaginal discharge, and cervical motion tenderness without a palpable pelvic mass. The clinical presentation is most consistent with A: Acute appendicitis. This is incorrect. Now remember on the NP boards and in these podcasts, I've mentioned this in the past, I am providing classic presentation of a condition, the classic presentation of appendicitis in a younger adult is about a 12 to 24 hour period of symptoms that include nausea with epigastric discomfort, then worsening discomfort that migrates to the right lower quadrant.
Dysuria, vaginal discharge would not be reported in appendicitis. And usually cervical motion tenderness is absent. B: Pelvic inflammatory disease. This is of course, the correct answer. And one more time, the patient is a member of an at-risk group for this condition, as it's often found in female adults under the age of 25 who have more than one sex partner or a partner who has more than one sex partner.
Cervical motion tenderness is a true classic finding that's fairly specific to the condition. The lack of palpable ovarian mass, not at all surprising. And because that represents tubo-ovarian abscess, it's not always found in PID. In addition, we're not told what her BMI is, but the reality is in a person with a larger body habitus, higher BMI, I've even noticed this in a person who's quite visibly toned, who has a thick abdominal wall of muscle-
It's really hard to palpate an adnexal mass, even if it was present. C: Ovarian cyst. Most often with an intact ovarian cysts is unilateral abdominal pain more like a low pelvic pain that sometimes can radiate to the ipsilateral thigh. Fever is absent because with ovarian cysts-there is no infection involved and there is no GI upset nor vaginal discharge with an intact ovarian cyst.
Often you'll hear a report of pain that's been present for a number of weeks to months. D: Ectopic pregnancy. Now you might say, ‘Yep,’ but here ectopic pregnancy, that's the can't miss potentially fatal. We got to make sure we roll this out. But listen to the patient's menstrual history. And you should also assume that if you're being given information on the NP boards, that the data presented is correct.
Her period just ended, normal timing, normal flow, and that really should lean you away from ectopic pregnancy. General rule that ectopic pregnancies are not symptomatic, like there's no belly pain-things along those lines until about 6 to 8 weeks into the pregnancy. Remember, with ectopic pregnancies, the term is almost synonymous with tubal pregnancy because something like 90-95% of all ectopics are in fact in the fallopian tube.
And what happens in ectopic pregnancy is the pregnancy grows, progresses till about 6 to 8 weeks of pregnancy, and then the tubes simply can no longer accommodate the pregnancy. And what happens is the abdominal pain, usually unilateral, starts at a point where the tube has stretched to the point can no longer accommodate the pregnancy. And that's, as I said, at about 6 to 8 weeks of gestation.
The vaginal discharge, this dysuria that was described would not be a typical finding in ectopic pregnancy, nor would the cervical motion tenderness be a typical finding. However, in even an intact ectopic pregnancy, the pelvic exam, you will find some unilateral tenderness with that, as a general rule, obviously, on the side of the pregnancy. The takeaway, as I've mentioned on a number of other podcasts, knowing how a disease presents clinically, in particular, if a patient is a member of an at risk group for the condition plus whatever the signs and symptoms are and how they will unfold, is key to the differential diagnosis process.
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