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8 - GUM Flashcards

1
Q

Symptoms of Trichomonas in F

A 
Vulval itching
Dysuria
Offensive smelling yellow frothy discharge
Abdominal pain
Vulval ulceration - occasional 
10-50% asymptomatic
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2
Q

Diagnosis of Trichomonas

A

Vaginal swab for saline wet microscopy

NAATS

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3
Q

Organism causing chlamydia infection

A

Chlamydia trachomatis intracellular gram negative bacteria

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4
Q

Symptoms of chlamydia in F

A 
Asymptomatic
Vaginal discharge
Low Abdominal pain
Deep Dyspareunia
Intermenstrual bleeding
Postcoital bleeding
Dysuria
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5
Q

Symptoms of chlamydia in M

A

Urethritis
Dysuria
Penile discharge

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6
Q

What is reiters syndrome

A

Urethritis arthritis and conjunctivitis

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7
Q

Diagnosis of chlamydia in men

A

NAATs. Testing on first void urine

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8
Q

Chlamydia diagnosis in women

A

Self-administered high vagina swab for NAATs testing

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9
Q

What type of organism is Trichomonas

A

Flagellated Protozoan

Parasite

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10
Q

What STI is a gram negative diplococcus

A

Neisseria gonorrhoea

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11
Q

On what samples is gonorrhoea diagnosed

A

NAATs on first void urine
Microscopy - gram stain
Culture - for sensitivities - done after NAATs +ve or known contact of GC

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12
Q

Symptoms of Trichomonas in M

A 
15-50% asymptomatic 
Urethral discharge 
Dysuria
Urethral irritation
Urinary frequency
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13
Q

Complications of TV

A

Preterm delivery
Low birth weight infants
TV at delivery may predispose to maternal sepsis
Association with HIV

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14
Q

Diagnosis of TV

A

F - Posterior fornix swab - NAATs

M - urethral culture / 1st void urine NAATs

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15
Q

What is seen on microscopy in TV

A

Mobile trichomonads on wet prep

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16
Q

How quickly must a wet prep slide be read for TV microscopy

A

10 mins - trichomonads quickly lose motility

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17
Q

Treatment of TV

A

Systemic treatment (as PV tx has 50% cure rate)
Metronidazole 2g PO STAT
Or metronidazole 400-500mg BD 5-7/7

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18
Q

Treatment of TV when metronidazole has failed

A

Tinidazole = longer serum 1/2 life 2g PO STAT

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19
Q

Duration of scabies lifecycle

A

4-6 weeks

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20
Q

How long does it take for scabies eggs to become adults

A

10-15 days

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21
Q

Mode of transmission of scabies

A

Close skin contact
Can be sexually transmitted
Formite transmission uncommon

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22
Q

Presentation of scabies

A

Intense, generalised pruritus - worse at night
Delayed IV hypersensitivity reaction to mites / faeces / eggs
Erythematous papules
Excoriation
Visible burrow

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23
Q

Duration between primary infection and symptom development in scabies

A

3-6 weeks

Infectious before symptoms develop

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24
Q

Common areas affected by scabies

A 
Webspaces, sides of fingers, under fingernails
Flexor side of wrist
Extensor side of elbow
Axilla
Around nipple, penis, scrotum
Around umbilicus, medial thigh, buttock
Side + back of feet
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25
Presentation of crusted scabies
``` Erythematous, crusted, scaly lesions Malodour Fissuring Affects any area of the baby including face + scalp Itching mild or absent ```
26
Management of scabies
5% permethrin cream - apply 8-12hr, repeat 1/52 0.5% malathion aqueous - apply 24hrs, repeat 1/52 25% benzyl-benzoate emulsion - not recommended
27
Treatment for crusted scabies
Permethrin cream OD for 7/7 then 2x/wk until cured | + PO ivermectin 200mcg/kg on day 1,2,8,9,15
28
Who should receive a Hep A vaccine
MSM who have oro-anal or digital anal contact
29
Who should receive Hep B vaccination
``` MSM CSW IVDU partner from high prevalence area HIV +ve ```
30
At what level do most labs detect a HIV viral load
50 copies / ml
31
Immediate needs for a sexual assault victim
``` Immediate safety Treat injuries - may need A+E 1st Baseline screen for STIs +/- prophylaxis Baseline HIV test and serum save HIV PEP Hep B vaccination EC Refer to SARC + forensic medical examiner Consider safeguarding and child protection issues Self harm risk assessment ```
32
Medium term needs for sexual assualt victim - disclosure after 7 days of assault
``` STI screening baseline + repeat 2/52 after assault Hep B vaccination Pregnancy test Assess coping Identify symptoms of PTSD psychological support ```
33
Long term needs for sexual assualt victim - disclosure after 1 yr of assault
``` STI screen Involve GP in psychological problems +/- counselling +/- CBT +/- antidepressants ```
34
What samples are taken in a police/A+E early evidence kit
Urine, mouth swab, mouth rinse
35
Forensic timescale for evidence from kissing / licking / biting
48 hours
36
Forensic timescale for evidence from oral penetration
48 Hours
37
Forensic timescale for evidence from vaginal penetration
7 days
38
Forensic timescale for evidence from digital penetration
12 hours
39
Forensic timescale for evidence from anal penetration
72 hours
40
Significance of a +ve STI result in a victim of a sexual assault
+ve STI result rarely important a evidence - hard to prove not pre-existing Concern a +ve result may be used to present victim as promiscuous. Important in child victims and the elderly Need clear chain of evidence - chronological documentation of collection, transfer + Analysis
41
STI prophylaxis regime for sexual assault victim
Ceftriaxone 500mg IM STAT Azithromycin 1g PO STAT metronidazole 2g PO STAT
42
Risk of HIV transmission from a known +ve source - for receptive anal and insertive anal
``` Receptive = 0.1-3% Insertive = 0.06% ```
43
Risk of HIV transmission from a known +ve source - for receptive vaginal and insertive vaginal
Receptive vaginal = 0.1 - 0.2% | Insertive vaginal = 0.03 - 0.09%
44
Risk of HIV transmission from a known +ve source - for receptive oral (fellatio)
Receptive oral = 0.04%
45
Risk of HIV transmission from a known +ve source - for mucous membrane exposure
Mucous membranes exposure = 0.09%
46
Risk of HIV transmission from a known +ve source - for needles tick injury
Needlestick injury = 0.3%
47
% risk of an assailant being HIV +ve in: London Scotland Elsewhere
``` London = 15% Scotland = 2.5% Elsewhere = 2.3% ```
48
Types of PEPSE available (2)
Truvada = tenofovir + emtricitabine OD Kaletra = lopinavir + ritonavir BD
49
Duration of PEPSE treatment
28 days
50
Side effects of PEPSE treatment
Nausea Vomiting Diarrhoea
51
Which patients groups need HIV specialist advice before starting PEPSE
Children Low BMI adults Pregnant women
52
When may Hep B immunoglobulin be considered
Within 48hours to 7 days of exposure to a known Hep B positive / high risk person
53
Risk of pregnancy from rape
5% | Higher than a single episode of consensual UPSI
54
What groups can gillick competency be applied to
Z
55
Symptoms of gonorrhoea in men
``` Asymptomatic 10% Urethral discharge Dysuria rectal infection - discharge / pain / asymptomatic Pharyngeal infection - asymptomatic Rare - epiddymal tenderness / swelling ```
56
Symptoms of gonorrhoea in women
``` Asymptomatic Vaginal discharge Lower abdo pain Dysuria Rare - intermenstrual bleeding / heavy bleeding Rectal infection Pharyngeal infection ```
57
Complications of gonorrhoea
``` Epididymo-orchitis Prostatitis PID Tubal infertility Ectopic pregnancy Haematogenous spread - Skin lesions/ arthralgia / arthritis/ teno-synovitis ```
58
Treatment of gonorrhoea
Ceftriaxone 500mg IM STAT + azithromycin 1g PO STAT If rectal + doxycycline 100mg BD 7/7
59
Treatment for gonococcal PID
Ceftiaxone 500mg IM + doxycycline 100mg BD 14/7 + metronidazole 400mg BD
60
Treatment of gonococcal epididymo-orchitis
Ceftriaxone 50mg IM | + doxycycline 100mg BD 10-14/7
61
Treatment of gonococcal conjunctivitis
3 day systemic treatment as the cornea may be involved + is relatively avascular Irrigate eye with saline Ceftriaxone 500mg IM OD 3/7
62
Look back window for PN of gonorrhoea
2/52 if symptomatic | 3m if asymptomatic
63
What FU is required for GC
Test of cure - due to resistance
64
Complications of chlamydia
``` PID Endometritis Salpingitis Tubal infertility Peri-hepatitis Ectopic pregnancy Sexually acquired reactive arthritis ```
65
Signs of chlamydia in F
Mucopurulent cervicitis Contact cervical bleeding Pelvic tenderness Cervical motion tenderness
66
Symptoms of rectal chlamydia
Asymptomatic Pain/ discomfort Anal discharge
67
Rates of rectal chlamydia in MSM
3-10%
68
% risk of tubal infertility after PID
20%
69
Management of chlamydia in F with IUD / IUS
Uncomplicated chlamydia is not an indication to remove IUD/IUS. Azithromycin 1g STAT PO
70
Management of chlamydia in pregnancy / breastfeeding
Doxycycline and ofloxacin CI Use azithromycin 1g PO STAT + test of cure
71
Symptoms of neonatal chlamydia
Ophthalmia neonatorum Conjunctivitis Pneumonia
72
Treatment of neonatal chlamydia
Erythromycin 50mg/kg 14/7 in 4 divided doses Test + treat mother
73
Most common organisms in non-gonococcal urethritis
``` Chlamydia Mycoplasma genitalium Ureaplasma Trichomonas Adenovirus Herpes simplex ```
74
Non infective causes of non-gonococcal urethritis
Urethral stricture | Foreign body
75
Symptoms of NGU
``` Asymptomatic Urethral discharge Urethral discomfort Dysuria Penile irritation ```
76
Complications of NGU
Epididymo-orchitis Sexually aquired reactive arthritis Reiters syndrome
77
How is the diagnosis of NGU made
>/= 5 polymorphonuclear leukocytes per high power field - averaged over 5 fields
78
Investigations for patients with urethral symptoms and negative urethral smear on microscopy
Leucocyte esterase dipstick - if >1+ likely smear was inadequate Reattend for early morning urethral smear if syx not settling
79
Treatment for NGU
Azithromycin 1g PO STAT Or doxycycline 100mg BD 7/7 If mycoplasma - azithromycin 500mg STAT then 250mg OD 4/7
80
Look back period for NGU PN
4 weeks
81
Treatment of persisting NGU after treatment
Azithromycin 500mg STAT then 250mg OD 4/7 | + metronidazole 400mg BD 5/7
82
Management of continuing symptoms of NGU after 2x courses abx
Consider moxifloxacin 400mg PO OD Consider abacterial prostatitis Consider chronic pelvic pain syndrome / psychological causes
83
Symptoms of trichomonas in men
Asymptomatic Urethral discharge Urinary frequency Prostatitis - rare
84
Look back period for PN in TV
4 weeks prior to syx onset
85
Most common cause of abnormal vaginal discharge in F of reproductive age
BV
86
What risk cut off is used to decide to give PEPSE
recommend PEPSE where significant risk of HIV transmission (risk>1/1000)
87
Risk of HIV transmission from known HIV +ve pt with receptive anal intercourse
No ejaculation 1:170 If ejaculation 1:65 Overall 1:90
88
Risk of HIV transmission from known HIV +ve pt with insertive anal intercourse
Not circumcised 1:161 | Circumcised 1:909
89
Risk of HIV transmission from known HIV +ve pt with receptive vaginal intercourse
1:1000
90
Risk of HIV transmission from known HIV +ve pt with insertive vaginal intercourse
1:1219
91
Risk of HIV transmission from known HIV +ve pt with semen splash to eye
<1:10,000
92
Risk of HIV transmission from known HIV +ve pt with receptive or I service oral sex
<1:10,000
93
Risk of HIV transmission from known HIV +ve pt for blood transfusion
1:1
94
Risk of HIV transmission from known HIV +ve pt with needle stick inj
1:300
95
Risk of HIV transmission from known HIV +ve pt with sharing inj equipment / Chen sex
1:149
96
Risk of HIV transmission from known HIV +ve pt with a human bite
<1:10,000
97
When is PEPSE by recommended after high risk contact with a known HIV +ve patient
if the source patient is on ART with a confirmed and sustained (>6 months) and undetectable plasma HIV VL (<200 c/mL)
98
What drugs are used as PEPSE
first-line regimen is Truvada and Raltegravir for 28 days.
99
How is PEPSE used
Start ASAP - within 72 hours. 28day course Follow-up HIV testing at 8–12
100
Other things to offer / do for patients requesting PEPSE
STI screen + repeat in 2 week Ultra rapid Hep B vaccination Preg test
101
Why may fly like symptoms during PEPSE course be a concern?
Consider seroconversion illness
102
Advice if missed PEP doses
<24 hour - continue - take missed one now and normal one at usual time 24-48 hr - continue >48 hour - stop
103
When is universal testing for HIV recommended
GUM / SHS AN TOP drug dependency services Patients diagnosed with TB, HBV, HCV and lymphoma All GP pts/ gen med admissions in an area of prevalence >2:1000
104
Respiratory clinical indicator disease for HIV testing
TB Pneumocystis Bacterial pneumonia Aspergillosis
105
Neurology clinical indicator disease for HIV testing
``` Cerebral toxoplasmosis Primary cerebral lymphoma Cryptococcal meningitis Progressive multifocal leucoencephalopathy Aseptic meningitis / encephalitis Cerebral abscess SOL Guillain-Barre Transverse myelitis Peripheral neuropathy Dementia Leucoencephalopathy ```
106
Dermatology clinical indicator disease for HIV testing
Kaposi sarcoma Severe seborrhoeic dermatitis Severe psoriasis Multi dermatomal / recurrent herpes zoster
107
Gastroenterology clinical indicator disease for HIV testing
``` Persistent cryptosporidiosis Oral candidiasis Chronic diarrhoea Oral hairy leukoplakia Weight loss of unknown cause Salmonella Shigella Campylobacter Hep B Hep C ```
108
Oncology clinical indicator disease for HIV testing
``` Non-hodgkin lymphoma Hodgkin lymphoma Lung cancer Anal cancer Seminoma Head and neck cancer Castlemans disease ```
109
Gynaecology clinical indicator disease for HIV testing
Cervical cancer VIN CIN grade 2+
110
Haematology clinical indicator disease for HIV testing
Unexplained thyrombocytopenia / neutropenia / lymphopenia
111
Ophthalmology clinical indicator disease for HIV testing
Cytomegalovirus retinitis Infective retinal diseases Unexplained retinopathy
112
ENT clinical indicator disease for HIV testing
Lymphadenopathy of unknown cause Chronic parotitis Lymphoepithelial parotid cysts
113
Primary HIV seroconversion symptoms
``` Fever Maculopapular rash Myalgia Pharyngitis Headache Aseptic meningitis ```
114
Cervical smear recommendation for HIV positive female
Annual
115
Contraception for HIV F on HAART
Depo Mirena IUD
116
What do fourth-generation HIV tests trustful test for?
HIV antibodies | P24 antigen
117
Window period for fourth generation HIV test
4 weeks after exposure
118
How to take prep
- Event based = 24 hours before sex and continue for 2 days after condomless sex - Daily regimen
119
Issues to consider when seeing children in SRH
``` Competency - Fraser guidelines Emotional maturity Psychological wellbeing Physical development Drug / alcohol use Age of partner Number of partners Current / previous sexual abuse / exploitation Other young people at risk - e.g. Siblings Social support Schooling Homelessness Grooming CSW Physical disabilities Learning difficulties STI / pregnancy risk ```
120
Is it mandatory to report sex in an <13yo to social services or the police
No. Must be considered case by case. Always a cause for concern but benefit of reporting needs to be weighed againstr encouraging the young person to seek / accept help.
121
Causative organism of LGV
Chlamydia trachomatis L1-3
122
Usual features of LGV
Transient small ulcer - may be unnoticed Lymphadenopathy Systemic - fever, malaise Buboes +/- rupture
123
Complications of LGV
``` Elephantitis Chronic oedema Rectal ulceration Fistula Adhesions ```
124
Causative organism of chancroid
Haemophilus ducreyi | Gram negative bacillus
125
Usual features of chancroid
Papule / pustule Inguinal lymphadenopathy Buboes possible
126
Causative organism of donovanosis
Calymmatobacterium (kebsiella) granulomatis
127
Usual features of donovanosis
Firm papule | Subcutaneous nodule may ulcerate
128
Can Vertical transmission occur with TV
Perinatally in 5% of female babies of infected mothers
129
Examination findings for TV in F
5-15% - no abnormality 70% - vaginal discharge Classically yellow and frothy 2% strawberry cervix
130
Examination findings in TV in M
No signs Urethral discharge - 20-60% Rarely balanoposthitis
131
Location of swab for TV
Posterior fornix
132
How to sample for TV in men
Urethral swab First void urine Sampling both increases pick up rate
133
Sensitivity and specificity of TV NAAT
Both almost 100%
134
Can metronidazole be used In pregnancy and breastfeeding
Yes - not teratogenic | May make milk taste bitter
135
Symptoms of thrush
``` Vulval itch / burning Curdy white discharge No smell External dysuria Superficial dysparunia Erythematous vulva ```
136
Signs of thrush
``` Erythema Fissuring Excoriation Oedema Satellite lesions White discharge ```
137
Definition of recurrent thrush
4+ episodes per year Either positive microscopy or culture grown Symptoms with partial / full resolution between
138
Predisposing factors for thrush
``` Sexual activity Antibiotics Hormone status Tight clothing Panty liners Uncontrolled DM Steroids HIV and immunosuppression ```
139
Treatment of thrush
Fluconazole 150mg PO stat | Clotrimazole 500mg PV stat or 200mg x 3 nights
140
Treatment of non-albicans candida
Standard azole treatment for 14 days
141
Common associations with BV
``` Change in partner Receiving cunnilingus Increased no of lifetime partners Smoking Black ethnicity IUD STI presence Menstruation Douching ```
142
Symptoms of BV
Vaginal discharge Fishy odour Watery white / yellow
143
Treatment of BV
Metronidazole 400mg BD for 5-7/7 | Alternative - 0.75% metronidazole gel or 2% clindamycin cream
144
Complications of BV
Risk factor for HIV acquisition Associated with STIs Increased risk of second trimester miscarriage and preterm birth Increased risk of endometritis after termination Stigmatisation
145
Define recurrent thrush
4+ episodes per year At least 2 with positive microscopy or culture. At least partial resolution between
146
Treatment of recurrent thrush
``` Longer treatment 7-14/7 Fluconazole 150mg 3x over 1 wk Fluconazole 50mg OD 7/7 Clotrimazole peasant 200mg OD 7/7 THEN Regular fluconazole 150mg weekly for 6m Or clotrimazole 500mg peasant weekly 6m ```
147
3 clinical features of reiters syndrome
Conjunctivitis Urethritis Arthritis
148
Organisms linked with triggering reactive arthritis
``` Chlamydia trachomatis Yersinia Shigella Salmonella Campylobacter Streptococcus viridans Mycoplasma pneumoniae ```
149
Risk of transmission of hepatitis B following a needlestick injury
20-40% if hep B eAg +ve | 1-6% if Hep B eAg -ve
150
Following a needlestick injury from a Hep B +ve patient who would require post-exposure prophylaxis
Non vaccinated staff and Non responders to the Hep B vaccine If the source is sAg +ve
151
What post-exposure prophylaxis is used for Hep B and what timeframe
Hepatitis B immunoglobulin within 24 hr | And rapid course Hep B vaccination
152
How many infected with Hep C clear the virus
20%
153
What treatment increases the chance of Hep C clearance
Interferon - alpha | Ribavirin
154
Management of a needlestick from Hep C PCR +ve patient
HCV antibody check ALT Baseline, 3m, 6m
155
Features of primary syphilis
Painless ulcer =Primary chancre At site of inoculation 10-90 days after contact localised lymphadenopathy
156
Features of secondary syphilis
``` Fever Headache Lethargy Macular then popular rash 50% have generalised lymphadenopathy ```
157
Define early latent syphilis
Treponema pallidum persists Asymptomatic Infection occurred in the last 12m Remain infectious
158
Define late latent syphilis
Asymptomatic syphilis Infection occurred >12m ago Not infectious Maternal to fetal transfer can occur
159
Define late or tertiary syphilis
``` Progressive inflammatory distressed Can affect any organ system - neurosyphilis - at any time - gummata in skin or visceral organs - 10+ yrs - Cardiovascular syphilis - 10+yr ```
160
Presentation of HSV encephalitis
Short prodrome of fever, lethargy, headache Severe CNS dysfunction Delirium Fluctuating consciousness Seizures Aphasia 60-80% progress to coma and death if untreated
161
Investigation for suspected HSV encephalitis
CSF PCR EEG MRI head - often normal in 1st 4 days then hypo-dense areas in temporal lobes
162
Treatment of HSV encephalitis
Aciclovir 10mg/kg 8 hourly IV Reduces mortality to <25% 14-21 days
163
What factors affect treatment outcome for Hep C
Viral genotype - 2 and 3 = better response High Hep C viral load Degree of hepatic fibrosis Alcohol consumption before and during treatment reduced effectiveness Age - success decrease by 5% with increased decade

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