Patient's question:
2012.12.28 First went to a private hospital for tests including Mycoplasma culture, identification, counting, and drug sensitivity. The report showed:Culture and identification in 24h: Uu (Ureaplasma urealyticum), positive.
Count: Uu ≥10^4.
In 48h: Mh (Mycoplasma hominis), negative.
Mh ≥10^4, negative.
A plus sign was written next to Uu and Uu ≥10^4.
A circle was drawn next to Mh and Mh ≥10^4.
Sensitivity: Tetracycline S, Ofloxacin I, Doxycycline S, Jiaozaoxin S, Sispamycin I, Roxithromycin S, Mezlocycline S, Levofloxacin I, Clarithromycin S, Azithromycin I.
Syphilis infection report:
Specific antibody test for Treponema pallidum: negative.
Non-specific antibody test for Treponema pallidum (unheated serum slide): negative.
TBS (Thinprep) report:
Magnification: 1:10.
Staining: HE.
Sample satisfaction: Satisfied.
Cell count: >5000.
Contains cervical canal cells and metaplastic cells.
Pathogens: No trichomoniasis, no candidiasis, no HPV infection, no herpes virus infection.
Others: No red blood cells, few inflammatory cells.
Cytological opinion: No intraepithelial lesions or tumor cells (NILM).
Additional opinion: Regular follow-up.
Vaginal discharge test:
Clinical diagnosis: Cervicitis.
Results: Yellow color, clear transparency, mucopurulent discharge, epithelial cells, white blood cells, urinary cells, red blood cells, and hyaline casts (all marked with circles).
Cleanliness: Degree 3.
Trichomonas vaginalis, clue cells, Candida, Gonorrea (Treponema pallidum) (all marked with circles).
BV (bacterial vaginosis) (chemical test), BCG (urine early pregnancy test), Chlamydia (colloidal gold test): all negative.
A sticker was attached showing: Leukocytes, ketones, nitrite, bilirubin, glucose, occult blood (all marked with dashes).
Urobilinogen, specific gravity, pH, creatinine, urine calcium, microalbumin (blank).
Protein: +1.
Colposcopy:
Colposcopic findings: Original squamous epithelium, columnar epithelium, white epithelium after acetic acid test, no color change after iodine test.
Colposcopic diagnosis: Chronic cervicitis: cervical erosion.
Ultrasound medical imaging report:
Findings:
Uterus: Anterior position, size 5.04.33.3cm, clear margins, homogeneous myometrium, endometrial thickness: 0.74cm.
Adnexa: Left ovary size 3.42.2cm, left ovary size 3.12.0cm, fluid-filled dark area in the uterine cavity with a distance of 2.5cm.
Ultrasound suggestion: Pelvic effusion.
Received vaginal medication for three days, administered daily at the hospital.
Later, on 12.30, visited the Maternal and Child Health Hospital for a vaginal discharge test:
Cleanliness: Degree 3.
Trichomonas vaginalis: not seen.
Candida: not seen.
Gonorrea (Treponema pallidum): not seen.
BV (bacterial vaginosis) test: pH≤4.4, mucicarmine positive, hydrogen peroxide negative, leucocyte esterase positive/negative/positive.
Prescribed medication: Nifuratel and clindamycin vaginal soft capsules (one box).
Then, on 1.18, underwent a follow-up examination with another doctor, who performed another vaginal discharge test:
Results similar to the previous test, except cleanliness degree 4.
Before the test, I used the restroom, unsure if it affected the results.
Prescribed medication: Terbinafine vaginal effervescent tablets (two boxes), to be used twice daily in the morning and evening. However, the instructions say once before bedtime.
After medication, excessive vaginal discharge occurred, and mild pain was felt in the menstrual cramping area.
Uncertain if the medication is still appropriate.
After numerous tests, no doctor has explained the specific gynecological condition, only prescribing medication and conducting tests.
Doctor's answer:
Considering it may be chronic pelvic inflammation, predominantly of the damp-heat type, the treatment principle is to clear heat and resolve dampness, with the main focus on invigorating blood and removing blood stasis. The herbal formula includes: Salvia miltiorrhiza 18g, Paeonia rubra 15g, Muxiang 12g, Persicae Semen 9g, Lonicera japonica 30g, Taraxacum mongolicum 30g, Poria 12g, Moutan Cortex 9g, Rehmannia glutinosa 9g. When the pain is severe, Przewalskia tangutica 9g is added. Some patients may have the cold congealing and qi stagnation type, for which the treatment principle is to warm the meridians, dispel cold, and promote qi circulation and blood flow. The modified Guizhi Fuling Decoction is commonly used. For qi deficiency, add Codonopsis pilosula 15g, Atractylodes macrocephala 9g, and Astragalus membranaceus 15g.