A 27-year-old nulligravid woman comes to the physician for evaluation of fertility. She has been unable to conceive for one year despite regular intercourse with her husband 1–2 times per week. Recent analysis of her husband's semen showed a normal sperm count. Two years ago, she had an episode of a febrile illness with lower abdominal pain, which resolved without treatment. Menarche was at age 12 and menses occur at regular 28-day intervals and last 4 to 5 days. Before her marriage, she was sexually active with 4 male partners and used a combined oral contraceptive pill with estrogen and progesterone consistently, as well as barrier protection inconsistently. One year ago, she stopped using the oral contraceptive pill in order to be able to conceive. She is 165 cm (5 ft 5 in) tall and weighs 84 kg (185 lb); BMI is 30.8 kg/m2. Physical examination shows no abnormalities. Which of the following is the most likely cause of this patient's infertility?

Long-term use of the oral contraceptive pill

A 23-year-old woman comes to the emergency department because of increasing abdominal pain with associated nausea and vomiting. The symptoms began suddenly after having intercourse with her partner six hours ago. There is no associated fever, diarrhea, vaginal bleeding, or discharge. Menarche was at the age of 13 years and her last menstrual period was 4 weeks ago. She uses combination contraceptive pills. She had an appendectomy at the age of 12. Her temperature is 37.5°C (99.5°F), pulse is 100/min, respirations are 22/min, and blood pressure is 110/70 mm Hg. Abdominal examination shows severe right lower quadrant tenderness with associated rebound and guarding. Pelvic examination shows scant, clear vaginal discharge and right adnexal tenderness. There is no cervical wall motion tenderness. Her hemoglobin concentration is 10.5 g/dL, leukocyte count is 9,000/mm3, and platelet count is 250,000/mm3. A urine pregnancy test is negative. Which of the following imaging findings is most likely?

Decreased ovarian blood flow on doppler

Increased ovarian blood flow on doppler

Complex, echogenic intrauterine mass

Distended fallopian tube with incomplete septations

A 19-year-old woman with no known past medical history presents to the emergency department with increasing lower pelvic pain and vaginal discharge over the last several days. She endorses some experimentation with marijuana and cocaine, drinks liquor almost daily, and smokes 2 packs of cigarettes per day. The patient's blood pressure is 84/66 mm Hg, pulse is 121/min, respiratory rate is 16/min, and temperature is 39.5°C (103.1°F). Physical examination reveals profuse yellow-green vaginal discharge and severe cervical motion tenderness. What is the most appropriate definitive treatment for this patient’s presumed diagnosis?

Clindamycin + gentamicin × 14 days

Levofloxacin and metronidazole × 14 days

A previously healthy 25-year-old woman is brought to the emergency department because of a 1-hour history of sudden severe lower abdominal pain. The pain started shortly after having sexual intercourse. The pain is worse with movement and urination. The patient had several urinary tract infections as a child. She is sexually active with her boyfriend and uses condoms inconsistently. She cannot remember when her last menstrual period was. She appears uncomfortable and pale. Her temperature is 37.5°C (99.5°F), pulse is 110/min, and blood pressure is 90/60 mm Hg. Abdominal examination shows a palpable, tender right adnexal mass. Her hemoglobin concentration is 10 g/dL and her hematocrit is 30%. A urine pregnancy test is negative. Pelvic ultrasound shows a 5 x 3-cm right ovarian sac-like structure with surrounding echogenic fluid around the structure and the uterus. Which of the following is the most appropriate management for this patient's condition?

Emergency exploratory laparotomy

Intravenous methotrexate administration

Oral doxycycline and metronidazole administration

A 45-year-old woman comes to the emergency department complaining of abdominal pain for the past day. The pain is situated in the right upper quadrant, colicky, 8/10, and radiates to the tip of the right shoulder with no aggravating or relieving factors. The pain is associated with nausea but no vomiting. She tried to take over-the-counter antacids which relieved her pain to a certain extent, but not entirely. She does not smoke cigarettes or drink alcohol. She has no past medical illness. Her father died of pancreatic cancer at the age of 75, and her mother has diabetes controlled with medications. Temperature is 38°C (100.4°F), blood pressure is 125/89 mm Hg, pulse is 104/min, respiratory rate is 20/min, and BMI is 29 kg/m2. On abdominal examination, her abdomen is tender to shallow and deep palpation of the right upper quadrant. Laboratory test Complete blood count Hemoglobin 13 g/dL WBC 15,500/mm3 Platelets 145,000/mm3 Basic metabolic panel Serum Na+ 137 mEq/L Serum K+ 3.6 mEq/L Serum Cl- 95 mEq/L Serum HCO3- 25 mEq/L BUN 10 mg/dL Serum creatinine 0.8 mg/dL Liver function test Total bilirubin 1.3 mg/dL AST 52 U/L ALT 60 U/L Ultrasonography of the abdomen shows normal findings. What is the best next step in management of this patient?

Reassurance and close follow up

A 63-year-old man presents to his family physician with limited movement in his left shoulder that has progressed gradually over the past 6 years. He previously had pain when moving his shoulder, but the pain subsided a year ago and now he experiences the inability to fully flex, abduct, and rotate his left arm. He had an injury to his left shoulder 10 years ago when he fell onto his arms and ‘stretched ligaments’. He did not seek medical care and managed the pain with NSAIDs and rest. He has diabetes mellitus that is well controlled with Metformin. His blood pressure is 130/80 mm Hg, the heart rate is 81/min, the respiratory rate is 15/min, and the temperature is 36.6°C (97.9°F). Physical examination reveals limitations of both active and passive abduction and external rotation in the left arm. The range of motion in the right glenohumeral joint is normal. The muscles of the left shoulder look less bulky than those of the right shoulder. There is no change in shoulder muscle power bilaterally. The reflexes and sensation on the upper extremities are normal. Which of the following is the next best step for this patient?

NSAID prescription for 1–2 weeks

No interventions are required at this stage

Three days after undergoing coronary artery bypass surgery, a 72-year-old man has severe right upper quadrant pain, fever, nausea, and vomiting. He has type 2 diabetes mellitus, benign prostatic hyperplasia, peripheral vascular disease, and chronic mesenteric ischemia. He had smoked one pack of cigarettes daily for 30 years but quit 10 years ago. He drinks 8 cans of beer a week. His preoperative medications include metformin, aspirin, simvastatin, and finasteride. His temperature is 38.9°C (102°F), pulse is 102/min, respirations are 18/min, and blood pressure is 110/60 mmHg. Auscultation of the lungs shows bilateral inspiratory crackles. Cardiac examination shows no murmurs, rubs or gallops. Abdominal examination shows soft abdomen with tenderness and sudden inspiratory arrest upon palpation in the right upper quadrant. There is no rebound tenderness or guarding. Laboratory studies show the following: Hemoglobin 13.1 g/dL Hematocrit 42% Leukocyte count 15,700/mm3 Segmented neutrophils 65% Bands 10% Lymphocytes 20% Monocytes 3% Eosinophils 1% Basophils 0.5% AST 40 U/L ALT 100 U/L Alkaline phosphatase 85 U/L Total bilirubin 1.5 mg/dL Direct 0.9 mg/dL Amylase 90 U/L Abdominal ultrasonography shows a distended gallbladder, thickened gallbladder wall with pericholecystic fluid, and no stones. Which of the following is the most appropriate next step in management?

Intravenous piperacillin-tazobactam therapy and percutaneous cholecystostomy

Intravenous heparin therapy followed by embolectomy

Careful observation with serial abdominal examinations

Endoscopic retrograde cholangiopancreatography with papillotomy

Pelvic inflammatory disease complications: High-Yield Surgery Lessons

🦠 Pathophysiology - Infection's Upward Spiral

Initiating Event: Ascending infection from the cervix/vagina, typically post-menses when the cervical mucus barrier is thin.
Primary Pathogens: Neisseria gonorrhoeae & Chlamydia trachomatis disrupt the endocervical barrier, facilitating the ascent of polymicrobial vaginal flora.
Inflammatory Cascade: Leads to mucosal damage, edema, and destruction of ciliated epithelial cells in the fallopian tubes, impairing ovum transport.

⭐ Fitz-Hugh-Curtis Syndrome: Perihepatic inflammation causing "violin-string" adhesions between the liver capsule and peritoneum. Presents with RUQ pain, often pleuritic, with normal LFTs.

⛓️ Complications - PID's Lasting Legacy

PID's inflammatory cascade leads to significant long-term sequelae, primarily from scarring and adhesions in the upper genital tract.

Infertility: Tubal scarring, hydrosalpinx, and occlusion. Risk increases with each episode.
Ectopic Pregnancy: Risk increases 6-10x due to damaged ciliary function and tubal obstruction.
Chronic Pelvic Pain: Common sequela (>18% of cases) from pelvic adhesions.
Tubo-ovarian Abscess (TOA): Acute, severe complication. Complex adnexal mass with fever/leukocytosis. Requires drainage & broad-spectrum IV antibiotics.
Fitz-Hugh-Curtis Syndrome: Perihepatitis. "Violin-string" adhesions between liver capsule and peritoneum. Presents with RUQ pain.

⭐ The risk of infertility is ~15% after one episode of PID, ~35% after two, and ~75% after three or more episodes.

Fitz-Hugh-Curtis syndrome adhesions

🔬 Diagnosis - Unmasking the Damage

Primary Imaging Modality: Transvaginal Ultrasound (TVUS) is the first-line test for suspected PID complications.

Specific Complication Findings:
- Tubo-ovarian Abscess (TOA):
  - TVUS: Complex, multiloculated adnexal mass with thick walls; tube and ovary are indistinguishable.
  - CT: Used for suspected rupture or to rule out GI pathology.
- Pyosalpinx/Hydrosalpinx:
  - TVUS: Dilated, sausage-shaped, fluid-filled fallopian tube.
  - 💡 "Cogwheel sign" indicates thickened endosalpingeal folds in pyosalpinx.
- Fitz-Hugh-Curtis Syndrome:
  - Laparoscopy (gold standard): "Violin-string" adhesions between the liver capsule and peritoneum.

Transvaginal US: Right tubo-ovarian abscess

⭐ Laparoscopy is the ultimate gold standard for diagnosing PID complications, allowing direct visualization and simultaneous therapeutic intervention (e.g., abscess drainage, adhesiolysis).

🧹 Management - The Aftermath Cleanup

Tubo-ovarian Abscess (TOA):
- Initial: Hospitalization + IV broad-spectrum antibiotics (e.g., Cefotetan/Cefoxitin + Doxycycline; or Clindamycin + Gentamicin).
- Failure to improve in 48-72 hrs or abscess >7-9 cm warrants drainage.
- Drainage options: Percutaneous (IR-guided) or surgical (laparoscopy).

Fitz-Hugh-Curtis Syndrome (Perihepatitis):
- Inflammation of liver capsule → "violin-string" adhesions.
- Treat underlying PID. Laparoscopic lysis of adhesions for persistent pain.

⭐ Fitz-Hugh-Curtis syndrome can present with acute RUQ pain, mimicking cholecystitis, but typically with normal LFTs and gallbladder ultrasound.

Chronic Sequelae:
- ↑ Risk of infertility (tubal factor), ectopic pregnancy, and chronic pelvic pain.

⚡ Biggest Takeaways

Tubo-ovarian abscess (TOA) is a severe complication presenting as a complex adnexal mass; requires IV antibiotics and possible drainage.

Infertility and increased risk of ectopic pregnancy are major long-term sequelae from tubal scarring and adhesions.

Fitz-Hugh-Curtis syndrome (perihepatitis) causes RUQ pain from "violin-string" adhesions on the liver capsule.

Chronic pelvic pain is a common, debilitating outcome resulting from pelvic adhesions.

Hydrosalpinx (fluid-filled, blocked fallopian tube) is another significant cause of infertility.

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