Approach to the critical patient
›First 5 minutes
›Monitoring and access
›Cardiac monitor for instability
›Two large bore IV lines for shock physiology
›Immediate tests
›Urine pregnancy test
›Point of care glucose in altered mental status
›Resuscitation
›IV crystalloid bolus for hypotension
›Early broad spectrum antibiotics for sepsis physiology
›Time critical imaging triggers
›Immediate pelvic ultrasound for positive pregnancy test with pain
›Immediate surgical consultation for peritonitis
›Diagnostic plan
›Pregnancy assessment first
›Urine pregnancy test
›Serum beta hCG if high suspicion with negative urine test
›Pelvic evaluation
›Speculum exam when feasible
›Bimanual exam for tenderness and masses
›Vaginitis testing
›pH testing
›Wet mount and KOH microscopy
›STI testing
›Gonorrhea NAAT
›Chlamydia NAAT
›Empiric and directed therapy
›Bacterial vaginosis treatment options
›Metronidazole 500 mg PO twice daily for 7 days
›Metronidazole gel 0.75 percent intravaginal once daily for 5 days
›Clindamycin cream 2 percent intravaginal at bedtime for 7 days
›Vulvovaginal candidiasis treatment options
›Fluconazole 150 mg PO once
›Fluconazole 150 mg PO once with repeat dose in 72 hours for severe symptoms
›Topical azole intravaginal for 7 days
›Trichomoniasis treatment
›Metronidazole 500 mg PO twice daily for 7 days
›Tinidazole 2 g PO once as alternative when appropriate
›Partner treatment required to prevent reinfection
›Uncomplicated gonorrhea treatment
›Ceftriaxone 500 mg IM once if under 150 kg
›Ceftriaxone 1 g IM once if 150 kg or higher
›Doxycycline 100 mg PO twice daily for 7 days if chlamydia not excluded
›Chlamydia treatment when gonorrhea excluded
›Doxycycline 100 mg PO twice daily for 7 days
›Azithromycin 1 g PO once in pregnancy
›Pelvic inflammatory disease outpatient regimen
›Ceftriaxone 500 mg IM once
›Doxycycline 100 mg PO twice daily for 14 days
›Metronidazole 500 mg PO twice daily for 14 days
›Pregnancy considerations
›Prefer topical azole therapy for candidiasis in pregnancy
›Avoid delaying ectopic evaluation when pregnancy test positive
›Reassessment
›Clinical response checkpoints
›Vital signs reassessment within 60 minutes if initially abnormal
›Pain reassessment after analgesia
›Result driven adjustments
›Modify antibiotics based on NAAT results
›Escalate to pelvic ultrasound if tenderness worsens
›Safety net triggers
›New fever after discharge
›Increasing pelvic pain