Title: Microsoft Word - Clinic Manual V2.docx
Author: bittlestonh
Last saved by: Jacqueline Coombe

Documenting pelvic inflammatory disease (PID)

The autofill (Best Practice) or management/comment (Medical Director) shortcut function in your medical practice software can be used to quickly insert information about PID into patient notes during a consult.  You can tailor the specific text to your own needs. Some suggestions for PID autofill text are provided below.

NAME OF SHORTCUT
PIDMX

SUGGESTED AUTOFILL TEXT
Presumptive diagnosis
[Pelvic inflammatory disease]

Differential diagnoses that are unlikely:
Pregnancy including ectopic [as negative urine pregnancy test]
Urinary tract infection [as no dysuria and urinalysis negative for nitrites] 
Appendicitis [as pain did not start unilaterally and associated genital symptoms present]
Ovarian cyst [as no unilateral symptoms, consider contraception method]

Presenting symptoms
[Recent onset lower abdominal pain, past xx days/weeks] 
[Dyspareunia] 
[Offensive vaginal discharge]
[Post coital bleeding, past xx days]
[Inter-menstrual bleeding]

Sexual health / STI history
[xx] number of partner/s, past 3 months 
Condom use [never, sometimes, always]
Previous STI check [never, xx months ago for chlamydia, gonorrhoea, other]
STI history [never, chlamydia xx months ago, gonorrhoea xx months ago, other]

Menstrual and contraceptive history
Last menstrual period [xx weeks/ months]
Irregular bleeding [yes / no describe]
Contraception method [specify method]

Intrauterine device
[IUD in situ – specify type of IUD]
[Advised that IUD can remain in place if symptoms are improving, but may need to be removed if no response to treatment within 48-72 hours at which point alternative contraception will be discussed]

Examination
Abdominal palpation [nil, mild, severe, rebound tenderness]
Speculum examination [cervicitis, vaginal discharge]
Bimanual examination [unilateral / bilateral adnexal tenderness, pain on moving cervix to one / two sides, pelvic mass]

Investigations
Urine sample [HCG to exclude pregnancy]
Vaginal swabs [trichomonas vaginalis, microscopy, culture, sensitivity (MCS) to check for bacterial vaginosis]
Cervical swabs [Chlamydia trachomatis, Neisseria gonorrhoea, Mycoplasma genitalium] 

Treatment
PID treatment prescribed [see Australian STI Management guidelines https://sti.guidelines.org.au/syndromes/pelvic-inflammatory-diseases-pid/] 
[Ceftriaxone 500 mg IM with 2 ml 1% lignocaine stat dose] 
[Doxycycline 100 mg bd for 14 days] 
[Metronidazole 400 mg bd for 14 days] 

Education and follow up
PID factsheet provided
Advised that most PID is sexually transmitted even if an STI is not diagnosed. Therefore advised patient that:
[their current sexual partner/s should be notified and tested for chlamydia, gonorrhoea, M. genitalium and treated if positive] 
[if they test positive for [chlamydia, gonorrhoea, M. genitalium] that past sexual partner/s should be notified per Australian contact tracing guidelines https://contacttracing.ashm.org.au/conditions/when-contact-tracing-should-be-considered/pelvic-inflammatory-disease-pid ].
Advised no unprotected sex until antibiotic treatment complete. 
Review appointment made for [72] hours, but advised to return earlier if symptoms worsen.
Advised that 
Preventing repeat infection will reduce the risk of repeat PID and complications
Risk of complications (eg. Infertility, ectopic pregnancy, pain) is reduced with prompt PID treatment