One might think that someone with suspected peritonsillar abscess would present with something akin to trench mouth. Like "Yuck Mouth" from the Schoolhouse Rocks days. One would, apparently, be wrong. My patient today told me that she had been having R-sided ear and throat pain of about one week's duration. Her throat pain was such that swallowing was excruciating.
Her exam went like this. Normal. Normal. Normal. Hmm.....
Her pharynx was distictly asymmetrical. No history of surgeries or traumas to the oropharynx. So much for just another URI. I looked again. And then again. The presentation hadn't changed. Inflamed and asymmetrical. And away to the ED she went.
Lesson: it's true that all of the "normals" inform your judgement when there is a physical exam finding that is decidedly abnormal.
My patient was describing to me what sounded like a UTI. Dysuria, frequency, urgency. The triumverate. But there was also the little issue of dyspareunia x 1 month. And something else that seemed significant at the time but escaped me now. Ah, yes - lower abdominal pain.
Now, new FNP is not unaware of the severity of PID and is keenly aware of needing a low index of suspicion in order to initiate treatment.
Throw in a little cervical motion tenderness (OK, a lot of CMT) and some suprapubic pain on exam and voila - I ordered my first Rocephin IM. No quinolones with breastfeeding, so she had to endure the torture of the injection, to say absolutely nothing of the significance of the diagnosis. Plus a 14-day course of Flagyl and some Doxy for her partner.
It felt so shitty to tell her that there is a very strong correlation between sexual intercourse and PID and, although I couldn't be certain of the diagnosis based on exam, I had to treat her given the potential for sequelae. Is it an STD? Is it just an ascent of normal vaginal flora? It depends and I'll probably never know what it is for her. For those interested, outpatient PID treatment in non-pregnant/breastfeeding patients consists of 500 mg of Flagyl BID x 2 weeks AND ofloxacin 400 mg BID x 2 weeks OR levofloxacin 500 mg QD. Some resources say 125 mg of IM Rocephin is an alternative to the quinolones; others say 250 mg. I gave 250 mg - reconstituted with 1mL of lidocaine to help ease the injection pain. PLUS partner treatment PLUS 2 weeks of abstinence or condoms until the infection clears. The CDC has really good treatment guidelines inline at http://www.cdc.gov/.
Lesson: The power we hold as practitioners is quite notable, worth reflecting upon and is essential to acknowledge as we approach our encounters. As I keep saying, I currently have the ability to take time to be with my patients during difficult times. I hope that I continue to make this a priority as I am expected to see more patients.
Saturday, September 17, 2005