Ms. Nancy Campbell is 25 years old and comes to the clinic complaining of dysuria that has lasted for
three days. Other accompanying symptoms include a
... [Show More] creamy vaginal discharge and an increased urination
frequency. Ms. Campbell’s symptoms differ from those of UTI as she explains. She is sexually active and
have more than one sexual partner and denies having protected sex instead opting for oral contraceptive
pills. She denies ever being pregnant before and denies other symptoms. Symptoms presented suit those of
cervicitis as described in this presentation. She denies chills, fever and other gastrointestinal symptoms
such as nausea and vomiting.
She was treated pharmacologically using Azithromycin 1000mg single dose to be taken orally and
ceftriaxone 250mg IM single dose after a series of lab tests. The management plan was accompanied by
patient education on abstinence and having protected sex.
This illness has a clinical significance as it puts the patient at the risk of getting endometriosis or Pelvic
Inflammatory Disease (PID). Other related risks are infertility, chronic pelvic pain and a higher risk of
ectopic pregnancy. The pathogens that cause this illness can be sexually transmitted to the patient's sexual
partners. According to Butaro, Trybulski, Polgar-Bailey & Sandberg, (2017), there is a high risk of
shedding and acquisition of HIV-1 in patients with cervicitis.
HPI
CC: A Burning sensation that comes with urination
History of Patient’s Illness: Ms. Nancy Campbell is a 25-year-old female patient who
presents to the clinic with a chief complain of three-day old dysuria. She reports of
a history of urinary tract infection and the burning sensation now is different from when
she had UTI. Patient reports that other accompanying symptoms include increased
urination frequency with urine that comes in small amounts. The patient reports that
she has a creamy vaginal discharge that happens three times a day. Patient denies chills
or fever, denies nausea, vomit or abdominal pain. Patient also denies breast tenderness.
Patient reports that dysuria is relieved by soaking in warm water. After a physical
examination, results show that there is a mucopurulent vaginal discharge that comes
from the cervix. Tenderness is also noted. Patient reports of being sexually active and
have more than one sexual partners and does not practice safe sex and instead takes
contraceptive pills as a means of preventing pregnancy.
Medical History
Patient had urinary tract infection twelve months ago.
No known allergies.
No medical intolerances
No chronic health complications or major traumas.
No hospitalization or surgeries are done before.
Medications: Oral contraceptive pills. And ibuprofen is taken for headache and
menstrual pains.
vaccinations are up to date.
Family History
Patient’s mother has type II diabetes and the father is battling high blood pressure,
hyperlipidemia and coronary artery disease (CAD). Patient has a sister older than her
and is healthy.
Social History
Ms. Campbell is a consultant and hence travels often. She reports to drinking two times
a week and she drinks 4 or 5 drinks when she drinks. She previously used to smoke and
denies other kinds of drug abuse. Patient has several sexual partners and denies using a
condom but rather uses oral contraceptives.
Review of Systems
General: Patient denies changes in weight, sweating at night, fever and chills. Denies
decreased energy levels.
Skin: Denies delayed healings, lesions or bruises. Denies moles or discolorations of the
skin.
Eyes: Denies using corrective lenses, blurred vision or changes in vision.
Ears: Denies ringing, discharge from the ears and hearing loss.
Nose/Mouth/Throat: Patient denies sinus complications, nose bleeds or dysphagia.
Denies dental complications, hoarseness or throat pain.
Cardiovascular: Denies irregular heartbeats, orthopnea, chest pains and edema.
Respiratory: Denies breathing complications, wheezing, coughing or dyspnea. Denies
a history of tuberculosis or pneumonia. [Show Less]