Case Study #48 – Cervicitis

Ellen Leon

Anatomy 2

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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

• Rash

• Joint discomfort/redness/swelling

• Muscle pain

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

8. Does the patient have any abnormal vital signs that could be related to her condition?

Vital Signs

BP 108/76 RR 12 Ht 5’11”

HR 65 T 99.5° F Wt 117 lbs

Head, Eyes, Ears, Nose, and Throat (HEENT)

• No rashes or other lesions

• Very warm and dry

Skin

• 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 Hematocrit 36%

Blood urea nitrogen 19 mg/dL Platelets 410,000/mm3

Creatinine 0.8 mg/dL White blood cells 12,750/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?

Normal Range: 4,800 – 10,800/mm3

Normal Range: 0.6 – 1.2 mg/dL

Normal Range: 8 – 20 mg/dL

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.