Transcript Case 64
Case Study #48 – Cervicitis Ellen Leon Anatomy 2 Disclaimer – Viewer discretion advised Background Information – History of Present Illness (HPI) • M.F. – 23 year old woman • 3 days of painful urination • Increasing amounts of a yellow, creamy vaginal discharge • Single, sexually active with 2 frequent partners • No contraceptives used • No intravenous drug use HPI – continued • Denies: • • • • • • • • • Active medical problems Oral/rectal intercourse Presence of wart-like lesions/painful blisters in genital region Vaginal bleeding Genital burning/itching Malodorous discharge Lower abdominal pain/pelvic pain Use of douches/deodorant tampons/perfumed products Last menstrual period – 3 days ago Patient Case Questions 1. What is the significance of the lack of wart-like lesions in the genital region? 2. What is the significance of the lack of painful blisters in the genital region? 3. What is the significance of the lack of use of spermicides, douches, or deodorant tampons? 4. What is the significance of the lack of use of any type of barrier contraceptive, like a diaphragm? 5. What is the significance of the lack of lower abdominal or pelvic pain? Past Medical History (PMH) • Genital herpes, 2 years ago • Syphilis, 6 years ago • Gravida 0 • No surgeries • Immunizations up to date except tetanus 6. What is the significance of the patient’s past medical history? Cervicitis • • • • Lower female reproductive tract disorder Inflammation of the cervix Infectious/non-infectious cause May be acute or chronic • • • Temporary pain only Can be caused by Chlamydia trachomatis or Neisseria gonorrhoeae May have severe complications if untreated • • • PID Miscarriage, infertility, Menstrual abdominal pain Symptoms • Abnormal vaginal bleeding after intercourse, in between periods, or menopause • Unusual vaginal discharge that doesn’t go away (grey, yellow, or white) • Painful sexual intercourse • General pain in the vagina • Frequent/painful urination • Pressure/heaviness in the pelvic region • Swelling/inflammation of the vagina/cervix • May be asymptomatic Pathophysiology • Tends to result from primary/direct infection of the cervix • Can be secondary, extending downward from the uterus or extending upward from the vagina • The inflamed cervix releases cytokines to the immune system, increasing WBC counts in that region. • Immune response can cause – • • Vasodilation of capillaries and arterioles (causing redness) Increased vasopermeability (vascular permeability) Causes and Risk Factors • Microbial agents, usually sexually transmitted (infectious agents) • Allergic reactions to chemical exposure (non-infectious agents) • Irritation from foreign objects • Common in women following labor and delivery • Early age, high-risk sexual behavior (“unsafe sex”) • Multiple partners • History of STDs • Alcohol abuse Family History (FH) • Father – recent balloon angioplasty • Mother – psoriasis, no other chronic conditions • Two brothers, alive and healthy Social History (SH) • Denies use of tobacco products • Has several beers on the weekends • Works as paralegal at local law firm • Does not seek routine medical care “Does not have very good medical coverage at this time” Review of Systems (ROS) • Denies • • • Headache Fever • • Joint discomfort/redness/swelling Muscle pain Rash 7. What is the significance of the information provided in the ROS? Medications • Uses birth control pills • Self-treats with acetaminophen for menstrual cramps Allergies • “Cedar fever” – allergy to mountain juniper • Demerol – “makes me goofy” Physical Examination and Laboratory Tests General Appearance • • • • • • • Young white woman, no apparent distress Healthy looking Tall, slim Talkative, quick to answer questions Appearing slightly nervous and angry Wears glasses Alert and oriented Vital Signs Vital Signs BP 108/76 RR 12 Ht 5’11” HR 65 T 99.5° F Wt 117 lbs 8. Does the patient have any abnormal vital signs that could be related to her condition? Skin • No rashes or other lesions • Very warm and dry Head, Eyes, Ears, Nose, and Throat (HEENT) • No signs of eye infection • Funduscopic exam normal • Tympanic membranes intact • Mucous membranes moist and pink • No erythema or edema of pharynx or oral ulcers • Good dentition 9. What is the significance of finding that there are no signs of an eye infection? Neck and Lymph Nodes • No cervical lymphadonepathy • Neck supple • No thyromegaly or carotid bruits Lungs • Normal breath sounds • Both lungs resonant • Good air entry Cardiac • Regular cardiac rate and rhythm • Two clear heart sounds • No murmurs Abdomen • No tenderness, rebound, or guarding • No hepatomegaly or splenomegaly 10. What is the significance of the negative abdominal findings? Genitalia • No lesions visible on vulva • Vagina with moderate amount of thick, yellow-white discharge and mild erythema • Cervix shows erythema and moderate yellow-white discharge from cervical os • No masses on bimanual exam • Cervical motion tenderness present Musculoskeletal and Extremities • No inguinal or axillary lymphadonepathy • No rashes or other lesions, cyanosis, clubbing, or edema (CCE) • Muscle strength and tone normal • Full range of motion throughout Neurologic • Cranial nerves II-XII intact • Patellar deep tendon reflexes grade 2+ bilaterally Laboratory Blood Test Results Laboratory Blood Test Results Sodium 137 meq/L Glucose, fasting 109 mg/dL Potassium 4.9 meq/L Hemoglobin 12.1 g/dL Chloride 107 meq/L Normal Range: 8 – 20 mg/dL Blood urea nitrogen 19 mg/dL Hematocrit 36% Creatinine 0.8 mg/dL White blood cells 12,750/mm3 Normal Range: 0.6 – 1.2 mg/dL Platelets 410,000/mm3 Normal Range: 4,800 – 10,800/mm3 11. Does the patient have any signs of renal failure? 12. Which of the laboratory test results listed above is abnormal, and why is the abnormal finding consistent with the diagnosis? Examination of Cervical-Vaginal Discharge • No yeast or hyphae seen • Increased white blood cells • Positive for intracellular gram – negative diplococci • Ligase chain reaction positive for both N. gonnorrhoeae and C. trachomatis 13. Based on the information, what is your assessment of this patient’s condition? 14. Is timing of possible exposure consistent with the incubation period for N. gonnorrhoeae? 15. How should this patient be treated pharmacologically? 16. Is an HIV test appropriate in this patient? Tests/Exams • Pelvic exam for swelling/tenderness • Bimanual exam to assess tenderness and enlargement of cervix • Specimen collection (like pap smear) for microscope • Rectal exams for some patients • Rare – colposcopy, biopsy of cervix Treatments • Antibiotic medication • Antiviral medication • Hormonal therapy • Cryosurgery • Electrocauterization • Laser therapy Treatment goals • Get rid of cervical inflammation and associated lesions • Prevent re-infection • Patient education on how to prevent • Identification of the microbe is crucial in a successful treatment.