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Mrs. Lina (21 y/o night club dancer) - Coggle Diagram
Mrs. Lina (21 y/o night club dancer)
History
21 years old female
Night club dancer
Is on oral contraceptive pills (OCP)
No history of using IUCD, douching, or local application of cream
Has similar problem for 6 months
No history of pregnancy and parturition
Has 2 partners
Increase risk to receive sexual infection
Sign and symptom
Yellowish vaginal discharge for 4 days
Chlamydia infection
Lower abdominal pain for 2 days
Pelvic inflammatory disease
Vaginal discharge gradually increased
Worsen infection
Investigation & Examination
Physical examination : All vital signs were normal
Oral examination : No oral thrush
Can rule out candida infection
Abdomen examination : Soft and symmetrical
Genital examination : No abnormal findings except yellowish vaginal discharge
Can rule out cancerous disease
Per speculum examination : Yellowish mucopurulent discharge
Indicate infection to genitalia
Bimanual pelvic examination : Cervical movement was tender, Uterus was normal in size, anteverted and Pouch of Douglas was tender
This is a normal findings
Normal
Diagnosis
Sexually Transmitted Disease due to Chlamydia infection
Treatment
Ceftriaxone and Doxycycline
An empirical treatment
Ceftriaxone was stopped and Mrs Lina was treated with
doxycycline alone.
Doxycycline is better to be used alone for chlamydia infection
Ceftriaxone : Bacterial infection
Doxycycline : Chlamydia infection