By Tedler D. Depaynos, MD
As part of pre-employment medical examination, a routine complete blood count (CBC) and urinalysis was done aside from other laboratory examinations. The 24 years old lady applicant unfortunately in her urinalysis revealed pus cells which are too numerous to count (TNTC) and red blood cells (RBC) which are significant in number. Her CBC also revealed a significant elevated white blood cell (WBC) count which implied the presence of infection. She was diagnosed to have a Urinary Tract Infection (UTI). Because it was supposed to be a simple infection and she was really in need of work, she was given the medical clearance. She was prescribed antibiotics which she was supposed to take for 10 days after which a repeat of her urinalysis would be done.
It was barely a week when she started working when she began experiencing pain in her left lower abdomen. It was initially on and off and bearable but after 2-3 days the pain became severe and felt that she was having slight fever. She was then forced to consult again the lady MD who gave her medical clearance.
The lady MD felt a slight rigidity on the left area of her abdomen compared to the right and the findings were similar to acute appendicitis except that it was on the left. She initially entertained a descending stone on the left ureter which has stopped. A descending stone causes severe pain and as it goes down it may cause bleeding. When she asked the patient if she has vaginal discharges, she thought of the possibility of Pelvic Inflammatory Disease (PID) as the cause of the pain when the patient answered in the affirmative. She then requested an ultra sound of the pelvic organs which may include the kidneys, ureters and the urinary bladder or KUB.
She regretted that she did not ask the patient earlier if she had vaginal discharges when she saw the results of the urinalysis and elevated WBC which implied infection. The urethral opening of females where the urine exit is at the vaginal opening and the urine may just be contaminated by the discharges. In collecting urine for examination, females are asked to douche first and have to collect at the midstream.
The discharges may have also caused the infection just like in this patient because as a rule, urinary tract infection (UTI) in females is due to ascending infection unlike in males that it may be descending coming even from the kidneys because of their long urethra. Of course ascending may also occur in males with very short organs.
The UTZ done was basically normal so that the patient was referred to a young OB-GYN MD.
PID is inflammation of the female genital organs are mostly due to infection. The infection may arise from the vagina causing vaginitis and after sometime may extend into the cervix and endometrium causing endometriosis and into the fallopian tubes, salphingitis and also into the ovaries, oophoritis. It may leak into the peritoneal cavity causing inflammation or peritonitis or even abscess formation. This may have occurred in the patient because of the severe abdominal pain and fever that she encountered.
In some cases, inflammation of the organs may cause it to enlarge due to swelling or be filled with pus like in salphingitis and this could sometimes be appreciated in the UTZ.
The infection of the female genital organs may be due to viruses, fungus or bacteria which could be a mixture of the gram negative or anaerobic ones. In rare cases, it may be due to tuberculosis(TB) or gonorrhea (GC). The incidence is obviously high in females with multiple sexual partners and it could be transmitted sexually. The patient is still single and claims that her boy friend left her years ago when he migrated abroad to join his parents. She denies any contact.
The OB-GYN MD then admitted her and gave massive antibiotics intravenously and the patient was closely monitored. If no improvement would be seen like no decrease in pain or relief from the fever, surgery may be the end result. An abscess may have formed causing the severe pain which must be drained. The peritoneum may have to be washed. The worst part is excision of the fallopian tube which could be filled with pus. This obviously will result in infertility especially if the other fallopian tube is also involved. Actually, the young OB-GYN is a trained laparoscopic surgeon and was ready to do the procedure if the conservative treatment was a failure.
Fortunately for the patient the antibiotics given worked fine and the patient swiftly recovered.
The patient was then discharged and advised to take her oral medications for at least a week more and return for follow-up. Likewise vaginal hygiene was advised.
Lucky for the patient, the company helped shoulder the hospital expenses because she was appointed as an employee just before hospitalization. The lady MD likewise promised herself to be more precise in issuing medical clearances. **
