Cathy, a 20-year-old college sophomore, visits the studenthealth center complaining of nausea, vomiting, and extremeabdominal pain. She says the pain came on suddenly after a meal, soshe is concerned about food poisoning. During the patient history,Cathy discloses that she is sexually active and has more than 10sexual partners per year. She uses oral contraceptives as herprimary method of birth control and does not rely on her partnersto use condoms. Cathy has a past history of vulvovaginitis,cervicitis, and numerous STDs (chlamydia, syphilis, and genitalherpes). Recently she has noticed a whitish vulva discharge with astrong odor that has increased in quantity over the past week.Cathy’s vital signs are as follows:

      Oral temperature =101.4ºF (38.6ºC)

Heart rate = 78 beats/min

      Respiratory rate = 15breaths/min

      Blood pressure = 150/86 mmHg

      A gynecological examination isperformed. Palpation of the abdomen reveals abdominal guarding,rebound tenderness, and an enlarged, painful uterus. A surgicalscar is also noted, and Cathy explains that her appendix wasremoved when she was a child. The external genitalia appearslightly edematous but are otherwise normal. Both the vulva and thecervix are slightly inflamed, and a purulent discharge is noted. Asample of the discharge is taken for culture, and a cell sample istaken from the external os for a Pap smear. During the pelvicexamination, movement of the cervix creates abdominal discomfort,and the rectovaginal examination confirms the uterine enlargementnoted upon palpation.

      Blood, fecal, and urethralsamples are obtained. Blood tests reveal leukocytosis but no HIVantibodies. The Pap smear is negative, and the cultures arepositive for Chlamydia and Neisseria gonorrhoeae.A pregnancy test (HCG assay) is negative. Ultrasound imaging of thepelvic cavity shows enlargement of the uterus and uterine tubeswithout pregnancy. Based on these test results, Cathy is diagnosedwith pelvic inflammatory disease.

      Cathy is prescribed a combinationof antibiotics and bed rest for 10 days. During this treatmentperiod, she is told to refrain from intercourse. She is alsoadvised to notify her partners about her condition and to encouragethem to seek treatment. In addition, Cathy is told to return for afollow-up examination after completing her medication to ensurethat the infections have been controlled. Finally, Cathy isencouraged to insist on condom use to minimize her chances ofcontracting STDs in the future. Because of her history of numerousSTDs, she is warned that she is at increased risk for infertilitydue to uterine tube scarring as well as for uterine and cervicalcancer.

1.Which of Cathy’s signs and symptoms are common to both pelvicinflammatory disease and appendicitis? Why is it important to ruleout appendicitis?

1. What signs and symptoms support the diagnosis of PID?
2. Suppose Cathy says that in spite of her “wildness” in college,she just wants to “get it all out of my system, and then settledown and have kids after I graduate.” As her physician, what wouldyou tell her about the relevance of her present behavior to herfamily plans?
3. Why are a Pap smear and an HIV test conducted?
4. Why do Cathy’s signs and symptoms rule out cervical,endometrial, and ovarian cancer?