Clinical Assessment The emergency physician should focus on identifying patients with relatively mild illness; the CDC encourages clinicians to err on the side of providing rather than withholding antibiotic treatment Additionally, the EM practitioner should identify women with relatively severe illness, through additional diagnostics, focusing on the consideration of major competing diagnoses Many patients with PID will have negative cultures, which does not exclude the diagnosis, as PID is a polymicrobial clinical syndrome rather than a specific bacterial infection FIGURE 92.3 Strategy for diagnosis of pelvic inflammatory disease (PID) Minimal laboratory evaluation should include tests for gonococcal and chlamydial cervicitis Expanded laboratory investigation may include, in addition to the minimal evaluation, complete blood cell count, Creactive protein or erythrocyte sedimentation rate, and pelvic or transvaginal ultrasonography (Adapted from Kahn JG, Walker CK, Washington AE, et al Diagnosing pelvic inflammatory disease A comprehensive analysis and considerations for developing a new model JAMA 1991;266:2594–2604.) An important pathophysiologic irony is the observation that tubal occlusion is associated more often with a relatively unimpressive clinical presentation of PID (i.e., long duration of symptoms, no signs of peritonitis, normal peripheral leukocyte count) than with a “hot” clinical disease (i.e., short duration of symptoms, fever, peritoneal signs, leukocytosis) Similarly, chlamydial PID is associated with both a longer duration of pain at patient presentation and a higher risk of infertility than is gonococcal PID Thus, if the diagnosis of PID is allowed to depend substantially on patients’ appearance—as either “well” or “sick”— clinicians may be tempted to reject the diagnosis of PID and to withhold