Failure to Diagnose & Delay in Treatment of Acute Abdomen Due to Pelvic Inflammatory Disease (PID)

Evaluate breaches in the standard of care when analyzing whether or not there was a Failure to Diagnose & Delay in Treatment of Acute Abdomen Due to Pelvic Inflammatory Disease (PID)

Answer the following questions to find out if the standard of care was followed for your case.

  • With which of the following medical emergency conditions did the patient present? (Choose all that apply)
    Septic shock
    Ruptured tubo-ovarian abscess
    Patient did not have any medical emergency
    Why is this important?
    Pelvic inflammatory disease is not typically a medical emergency, except when the patient is septic or has a ruptured tubo-ovarian abscess. These complications should be considered during the initial evaluation.
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  • With which of the following symptoms did the patient present? (Choose all that apply) Why is this important?
    Answer this question
    
Signs and symptoms of Pelvic Inflammatory Disease (PID) are variable. Lower abdominal pain is the most frequent complaint. Patients may also have vaginal discharge, bleeding, dysuria, dyspareunia, fever, malaise, or they may be asymptomatic.

    (2011) 29 EMDCNA 3 621-635 



  • Was a medical history obtained? Why is this important?
    Answer this question
    
A complete medical history and carefully focused physical examination serve as the core of the diagnostic process. The information obtained guides the further direction of the patient's evaluation and enables the clinician to make the most judicious use of additional tests. 

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  • With which of the following risk factors did the patient present? (Choose all that apply) Why is this important?
    Answer this question
    
A risk factor is a variable that has a causal association with a disease or disease process; the presence of the variable in an individual or a population is associated with an increased risk of the presence or future development of the disease. Thus, risk factors may be useful for identifying subjects at increased risk for a disease or for a particular outcome that results from a disease process.

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  • Was a physical examination performed? Why is this important?
    Answer this question
    
A complete medical history and carefully focused physical examination serve as the core of the diagnostic process. The information obtained guides the further direction of the patient's evaluation and enables the clinician to make the most judicious use of additional tests. 

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  • Which of the following diagnostic laboratory investigations were performed? (Choose all that apply) Why is this important?
    Answer this question
    
Routine laboratory studies can provide important clues to diagnosis.

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  • Which of the following diagnostic imaging studies were performed? (Choose all that apply) Why is this important?
    Answer this question
    
Ultrasound is the imaging modality of choice for the evaluation of pelvic pain. Computed Tomography (CT) scanning provides superior bone imaging and is an excellent modality to delineate abnormalities identified by another imaging modality. Magnetic Resonance Imaging (MRI) provides unprecedented clarity in depicting soft tissue structures such as ligaments and tendons and also can delineate bone marrow changes associated with stress fractures before radiographic abnormalities appear. MRI can be helpful both in guiding management decisions and in following the patient's response to therapy.

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  • With which of the following did the patient present? (Choose all that apply) Why is this important?
    Answer this question
    
The most specific criteria for diagnosing pelvic inflammatory disease include endometrial biopsy suggesting endometritis, transvaginal sonography or magnetic resonance imaging showing tubal hyperemia, laparoscopic abnormalities consistent with pelvic inflammatory disease.

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  • To which of the following specialists was the patient referred? (Choose all that apply) Why is this important?
    Answer this question
    
Once a diagnosis has been made, and in many cases if a diagnosis is unclear, referral to the appropriate specialists needs to be made in a timely manner. To deliver care requires a coordinated approach that allows sharing of skills and expertise. The skills of members from all professional disciplines should be utilized. 

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  • Was the patient discharged and later diagnosed with pelvic inflammatory disease? Why is this important?
    Answer this question
    
Diagnosis is difficult because of the variable presentation of pelvic inflammatory disease and potentially mild symptoms. Providers must have a high suspicion for this diagnosis in young, sexually active women and a low threshold for treatment, given the long term consequences of untreated disease such as infertility, ectopic pregnancy and chronic pelvic pain.

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  • For which of the following conditions was the patient not hospitalized? (Choose all that apply) Why is this important?
    Answer this question
    
Except for patients with the mildest forms of pelvic inflammatory disease, most patients are hospitalized so that intravenous antibiotics can be given. The criteria for hospitalization are moderate to severe illness (high fever, nausea and vomiting), uncertain diagnosis (appendicitis, ectopic pregnancy), and inability to tolerate oral treatment or adhere to treatment, failed outpatient management, tubo-ovarian abscesses, pregnancy and HIV positive status. 

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  • Which of the following treatment options were not initiated? (Choose all that apply) Why is this important?
    Answer this question
    
The main goal of treatment is to provide prompt, appropriate antimicrobial therapy to decrease pain, improve symptoms, and to minimize risks of progressive infection and associated tubal damage. 

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  • Which of the following indications for surgery did the patient possess? (Choose all that apply) Why is this important?
    Answer this question
    
If no clinical improvement occurs, further diagnostic workup is necessary, including possible surgical intervention.

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  • Was an informed consent obtained? Why is this important?
    Answer this question
    
The laws of most states require that surgeons obtain informed consent before providing treatment.

    (2011) 23 EOMSCA 3 475-484 



  • Was a pre-operative evaluation performed? Why is this important?
    Answer this question
    
A pre-operative basic health assessment is typically performed within 30 days of planned surgery. At least a limited assessment is mandated by the Joint Commission on Accreditation of Healthcare Organizations on all patients, but a more thorough evaluation is necessary to obtain a comprehensive view of patient risk factors.

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  • Which of the following procedures were performed? (Choose all that apply) Why is this important?
    Answer this question
    
Incision and drainage of tubo-ovarian abscess, unilateral adnexectomy and laparoscopy are performed if the patient does not respond to conservative management after 48 to 72 hours or there is suspicion of an acute abdomen with concern about ruptured tubo-ovarian abscess or peritonitis.

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  • Was post-operative care provided? Why is this important?
    Answer this question
    
When monitoring the patient, the physician must periodically re-evaluate the initial assessment to ensure optimal treatment and to recognize potential latent symptoms of serious underlying conditions. 

    (2008) 89 APMERE 9 1830-1845.e4 



  • Were clinical re-evaluations advised for patients managed as out-patient? Why is this important?
    Answer this question
    
Patients who are managed as outpatients should undergo clinical evaluation after 48 to 72 hours. Substantial improvement should be seen at this follow-up visit. If the patient has not improved, consider re-evaluation of the diagnosis, development of tubo-ovarian abscesses or inappropriate antibiotic coverage. Plan for in-patient management should be done.

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  • Did the patient respond to out-patient therapy? Why is this important?
    Answer this question
    
Patients who are managed as outpatients should undergo clinical evaluation after 48 to 72 hours. Substantial improvement should be seen at this follow-up visit. If the patient has not improved, re-evaluation of the diagnosis is considered, development of tubo-ovarian abscesses or inappropriate antibiotic coverage.
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