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Pelvic pain can be caused by many reasons such as ovarian cysts, urinary tract infections, appendicitis, sexually transmitted infections, pelvic inflammatory disease (PID)…In this discussion, I will address PID as the cause of pelvic pain. PID is an infection or inflammation of the upper genital tract in women (Shen et al., 2016). For PID, it is considered acute if the symptoms last 30 days or less (Ferri, 2018). The condition is chronic if the symptoms last more than 30 days. PID is a sequela of sexually transmitted infections, so it is commonly diagnosed in young and sexually active women. Patients usually complain of lower abdominal pain, abnormal vaginal discharge/ bleeding, postcoital bleeding, dysuria, dyspareunia, or fever (Ferri, 2018). If a patient also complains of nausea and vomiting, we need to rule out peritonitis. Since the disease can cause infertility, ectopy pregnancy and can permanently damage other organs such as the uterus, ovaries, fallopian tubes, the patient needs to be referred to a gynecologist immediately to have a proper treatment (Shen et al., 2016). Some women may not have any symptoms, so we need to do a thorough history and physical examination, as well as offer STI screenings to avoid underdiagnosis. We can order basic labs and imaging studies such as urinalysis and urine culture, CBC, CMP, CRP, ESR, and ultrasound pelvic/transvaginal so that the patient can have them done before seeing the gynecologist. An endometrial biopsy or laparoscopy can be done by the gynecologist to confirm the diagnosis of PID (Ferri, 2018).
To write a referral to a specialist, we first need to include our information (name, address, phone, fax, email) and the specialist’s information. Second, the reason for consult/referral, the patient’s biographical data, chief complaint, history of present illness, past medical history, allergies, current medications, family history, social history, vital signs, review of system, and physical examination need to be addressed. Also, we need to include labs and imaging studies, treatment plan, diagnosis, and recommendations. After the patient has been seen and treated by the gynecologist, we are responsible for advising the patient to come back to see us for follow-ups. Since PID can be recurrent, the patient needs to be tested for gonorrhea and chlamydia three to six months after the treatment (Ferri, 2018). Her sexual partner needs to be treated as well to prevent her from being re-infected. Untreated gonorrhea and chlamydia can cause PID; therefore, it is essential for NPs to screen female patients aged less than 25 and those at increased risk for these infections to reduce the incidence of PID (Kreisel, Torrone, Bernstein, Hong, & Gorwitz, 2017). We also need to offer HIV and other STI screenings to all women with PID.
Endometriosis is a painful disorder that results from the endometrium growing outside of the uterus. This generally involves the pelvic region, ovaries, fallopian tubes and the pelvic lining. It can affect areas outside of the pelvic region as well. Though the endometrium is displaced, it continues to act as normal by thickening, breaking down and then bleeding during menstruation. Unfortunately, there is no place for this to go and it becomes trapped. Eventually, this causes scarring and adhesion’s which cause pelvic organs to adhere together. All this together causes the pain and can lead to infertility (Mayo Clinic, 2018). I chose this subject because I had endometriosis. It is a horrible disorder and very painful. There were times that it felt like someone was stabbing my insides with a knife. I would ball up into the fetal position and cry until the pain went away. I eventually had to have a hysterectomy at the age of 29. This was horrible because we tried to have another baby, but it left me unable to have anymore. I was so bad that I had bleeding outside of my menstrual cycle and it was in my rectum. Before my surgery, I bleed for more than 2 weeks straight despite medications. He said if I did not have the surgery, I would eventually hemorrhage.
(Youngkin, Davis, Schadewald & Juve, 2013)
Endometriosis generally does not require a referral. With this being said, women may become infertile with this issue (Johns Hopkins, 2018). If the woman would like to have children and has infertility issues, she can be referred to a fertility specialist. Some women require hysterectomies if the disease is severe (Johns Hopkins, 2018). In some cases, the woman may need to be referred to a physician within the practice that performs this.
Follow-up After Referral
It is known that 17-19% of women with endometriosis have spontaneous resolution of lesions. Many more women have a progression of lesions. This makes up 24-64% of the cases. Others remain stable. This is 9-59% of the cases. Follow-ups will depend on the treatment plans that are decided on. There should be, at the very least, a three-month follow-up to report any new, worsening or resolving symptoms. At the follow-up, side effects of treatment should be discussed as well. This follow-up can be used to discuss further pregnancy options if need be (Youngkin, Davis, Schadewald & Juve, 2013).
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