Nancy cambel ihuman

NANCY CAMPBELL

CERVICITIS

NSG 6430

October 9, 2018

SUMMARY

The incidence of upper genital tract infection is caused by microbes that infiltrate the

uterus and the fallopian tubes. Infections of the upper genital tract can be caused by

sexually transmitted infection (STI’s). The symptoms of STI’s can manifest as

abdominal discomfort, abnormal vaginal discharge, fever, painful urination,

dyspareunia or prolonged excessive uterine bleeding. The most common STI’s

reported is chlamydia and gonorrhea. Chlamydia can present as asymptomatic and

gonorrhea can result in resistance due to commonly used antibiotics for treatment

particularly in uncured patients.

(Kirkcaldy et al., 2015)

HPI

 Chief Complaint: “Painful urination for the past three days”.

 HPI: A 25 year old Caucasian female that reports for the past three days she has

had painful urination. She also has frequency in urination and a vaginal discharge.

She rates her discomfort a 4/10. To alleviate her symptoms she soaks in warm

water which helps. She denotes that she has multiple sexual partners and does not

barrier protection she is taking oral contraceptives daily. She had her menses two

and a half weeks ago and she indicates that it lasted five days. She indicates that

the discomfort is not like the urinary tract infection she had one year ago.

MEDICAL HISTORY

Medications: Ethinyl

estradiol/drospirenone

PO QD, Ibuprofen as

needed

PHM: None Allergies: NKDA

Medication

Intolerances: None

Chronic Illness/Major

Traumas: None Hospitalization: None

FAMILY HISTORY

 Mother has diabetes mellitus

 Father has coronary artery disease, hypertension, and hyperlipidemia

 Sister is healthy

SOCIAL HISTORY

 A 25 year old Caucasian single woman that works as a consultant. She drinks one

to two times per week and drinks four to five drinks on occasion. She is an exsmoker with a two pack a year history. She denies using illicit drugs or

prescription medications. She is sexually active and has multiple sexually partners

and does not use condoms.

REVIEW OF SYSTEMS

General

Denies weight changes, fatigue, fever, chills, night sweats, or

decreased energy level.

Cardiovascular

Denies chest pain, palpitations, PND, orthopnea, or edema

Skin

Denies delayed healing, rashes, bruising, bleeding, or skin

discoloration, any changes in lesions or moles.

Respiratory

Denies cough, wheezing, hemoptysis, dyspnea, pneumonia history, or

TB

Eyes

No use of corrective lenses. Denies blurring, visual changes of any

kind

Gastrointestinal

Denies abdominal pain, nausea vomiting, diarrhea, constipation,

hepatitis, hemorrhoids, eating disorders, ulcer, or black tarry stools

Ears

Denies ear pain, hearing loss, ringing in ears, or discharge

Genitourinary/Gynecological

Patient reports dysuria, urinary frequency, and urgency. She denies

nocturia, incontinence, or change in color of urine. She is sexually

active with multiple partners. She uses oral contraceptive. She has no

known history of STI. Her Pap smears have always been normal in

the past. No pregnancies. LMP was two and a half weeks ago. She

has a menses that last five days and is a normal flow.

REVIEW OF SYSTEMS cont.

Nose/Mouth/Throat

Denies sinus problems, dysphagia, nose bleeds, or discharge,

dental or gum disease, hoarseness, or throat pain

Musculoskeletal

Denies back pain, joint swelling, stiffness or pain, fracture history,

or osteoporosis

Breast

Completes SBE. Denies lumps, bumps, discharge or dimpling

Neurological

Denies syncope, seizures, transient paralysis, weakness,

paresthesia, or black out spells

Heme/Lymph/Eno

Denies HIV. Denies bruising, blood transfusion history, night

sweats, swollen glands, increase thirst, increase hunger, cold or

heat intolerance

Psychiatric

Denies mood changes, depression, anxiety, sleeping difficulties,

suicidal ideation, or attempts