Differential Diagnosis for the 28-year-old Female Patient

The patient presents with a complex array of symptoms including severe lower abdominal and pelvic pain, dysuria, hematuria, abnormal vaginal bleeding, and a history of recurrent bacterial vaginosis. Considering her symptoms and history, the differential diagnoses can be categorized as follows:

• Single Most Likely Diagnosis

  • Pelvic Inflammatory Disease (PID): Given the patient's history of recurrent bacterial vaginosis, symptoms of severe lower abdominal and pelvic pain, abnormal vaginal bleeding, and the onset of symptoms after intercourse, PID is a highly likely diagnosis. The presence of thick, yellow vaginal discharge and a faint fishy odor further supports this diagnosis.

• Other Likely Diagnoses

  • Urinary Tract Infection (UTI)/Pyelonephritis: The patient's symptoms of dysuria, hematuria, and urinary urgency are consistent with a UTI. The passage of a possible stone could also be related to a UTI or pyelonephritis, especially if the stone is causing an obstruction.
  • Sexually Transmitted Infections (STIs): Given the patient's history of possible STD exposure and symptoms of pelvic pain and abnormal vaginal bleeding, STIs such as gonorrhea or chlamydia should be considered.
  • Kidney Stones: The patient's symptoms of severe pain radiating from the lower abdomen to the back and sides, associated with urinary urgency and the passage of a possible stone, are consistent with kidney stones.

• Do Not Miss Diagnoses

  • Ectopic Pregnancy: Although the patient reports having had her period, an ectopic pregnancy could still be possible, especially if the patient has irregular periods or if the pregnancy test is not sensitive enough to detect early pregnancy. This diagnosis is critical to rule out due to its potential for severe morbidity and mortality.
  • Ovarian Torsion: Sudden onset of severe pelvic pain could be indicative of ovarian torsion, a condition that requires immediate surgical intervention to preserve the ovary.
  • Septic Abortion: If the patient is indeed pregnant and has undergone an abortion (spontaneous or induced), septic abortion is a life-threatening condition that must be considered.

• Rare Diagnoses

  • Mittelschmerz: Although less likely given the severity of the patient's symptoms, mittelschmerz (ovulatory pain) could be considered if the patient's symptoms coincide with ovulation.
  • Endometriosis: While endometriosis could explain some of the patient's symptoms such as pelvic pain and abnormal vaginal bleeding, it is less likely to cause the acute onset of severe symptoms described in this scenario.