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Question 10#

A 28-year-old woman presents to her internist with a 2-day history of low-grade fever and lower abdominal pain. She denies nausea, vomiting, or diarrhea. On physical examination, there is temperature of 38.3°C (100.9°F) and bilateral lower quadrant tenderness, without point or rebound tenderness. Bowel sounds are normal. On pelvic examination, an exudate is present and there is tenderness on motion of the cervix. Her white blood cell count is 15,000/µL and urinalysis shows no red or white blood cells. Serum β-hCG is undetectable. Which of the following is the best next step in management?

A) Treatment with ceftriaxone and doxycycline
B) Treatment with ciprofloxacin and metronidazole
C) Diagnostic laparoscopy
D) CT scan of abdomen and pelvis
E) Aztreonam

Correct Answer is A


This patient presents with the clinical picture of pelvic inflammatory disease (PID), including lower quadrant tenderness, cervical motion tenderness, and adnexal tenderness. Fever and mucopurulent discharge are additional evidence for the diagnosis. Treatment requires antibiotic therapy. Ceftriaxone and doxycycline are one recommended regimen that would cover both N gonorrhoeae and C trachomatis. Resistance to fluoroquinolones has emerged in the gonococcus, so previous regimens based on ciprofloxacin or ofloxacin are outdated. The combination of ciprofloxacin and metronidazole would be appropriate if gut organisms were the only pathogens to be covered (for instance, in acute diverticulitis). At times, surgical emergencies may mimic PID and require hospitalization for further observation. CT scan is an excellent diagnostic test for acute appendicitis, but the specific findings of cervical motion tenderness, discharge, and bilateral tenderness all distinguish PID from appendicitis in this patient. Diagnostic laparoscopy is the gold standard for the diagnosis of PID, but this expensive and invasive test is unnecessary in uncomplicated cases. Aztreonam has good gram-negative coverage but does not adequately cover the sexually transmitted pathogens.