Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with lower abdominal/pelvic pain of [duration]. Associated symptoms include [abnormal vaginal discharge/post-coital bleeding/dysuria/fever/chills]. Denies recent instrumentation or pregnancy. LMP: [date]. Sexual history: [number of partners/barrier contraception use/history of STIs].
Clinical Examination Findings
Abdominal exam: Tenderness to palpation in lower quadrants, no rebound or guarding. Pelvic exam: Mucopurulent cervical discharge noted. Cervical motion tenderness (CMT) present. Adnexal tenderness: [Right/Left/Bilateral]. Uterine tenderness: [Present/Absent]. No palpable adnexal masses.
Treatment Protocol
Initiate empiric antibiotic therapy for PID per CDC guidelines: Ceftriaxone 500mg IM single dose, plus Doxycycline 100mg BID for 14 days, with or without Metronidazole 500mg BID for 14 days. Advise partner notification and treatment. Abstain from sexual activity until treatment completion and resolution of symptoms.