Day 13 Sexual Health Flashcards
A 24 year old lady presents to the GP surgery with vulval irritation.
She also explains that her vaginal discharge has changed recently. It is now thick and white, she has not noticed a foul smell.
She is sexually active and she is on the mini pill so she does not use condoms with her partner.
What is the most likely diagnosis?
Thrush (vaginal candidiasis)
A 19 year old woman attends her GP 22 weeks into her first pregnancy.
She complains she has developed painful lesions on her vulva.
She is otherwise well.
She has no history of previous sexually transmitted infections and is currently sexually active.
On examination, her observations are normal.
There are multiple wet ulcer-like vesicles on her vulva and perineum which are painful to touch, with surrounding erythema.
There is palpable inguinal lymphadenopathy.
What is the diagnosis?
What is the most appropriate treatment?
Oral Aciclovir 400mg three times a day
This woman has a primary herpes simplex virus (HSV) genital infection. Treatment with oral Aciclovir should be given immediately following clinical diagnosis.
A higher dose of 400mg three times a day is required due to the higher circulating blood volume found in pregnancy.
Acquisition of primary genital herpes simplex in the first or second trimester does not preclude vaginal delivery, however suppressive therapy with oral Aciclovir may be given from week 36 to reduce the risk of HSV lesions at term.
If this woman has HSV lesions at term, delivery via caesarean section is recommended to reduce the risk of vertical transmission to the newborn.
A 40 year old male presents to A&E with an acute onset of severe, generalised abdominal pain that began this morning.
He has been experiencing fevers, night sweats and non-bloody diarrhoea for the past 1 week.
He has no recent travel history.
He is a known HIV positive patient currently on antiretroviral therapy.
Liver function tests show:
- Bilirubin 11 µmol/L
- ALT 32 iU/L
- AST 35 iU/L
- ALP 358 iU/L
- GGT 15 U/L
- LDH was 410 iu/L
What is the most likely causative organism?
What is the diagnosis?
Mycobacterium avium intracellulare
This usually occurs in the immunocompromised, and causes abdominal pain due to intra-abdominal lymph node enlargement.
ALP and LDH are typically elevated.
It may cause pulmonary, gastrointestinal and disseminated disease (particularly in HIV patients).
A 23 year old male has recently returned from an extended stay abroad.
He is complaining of a fever, sore throat, mouth ulcers and upon inspection it is noted there is a widespread maculopapular rash on his chest.
What is the next most appropriate investigation?
HIV antibody + HIV antigen test
The presence of the maculopapular rash on the upper areas and mucosal ulcers are the most specific signs for primary HIV infection.
There should be a high index of suspicion in this case, with prompt HIV testing being required
A 27-year old female presents with right upper quadrant (RUQ) pain and fever.
Her last menstrual period was 2 weeks ago, and she was last sexually active 10 weeks ago.
They did not use a condom, but she is on the oral contraceptive pill.
Her past medical history includes an appendectomy only.
She is febrile but other observations are stable.
On abdominal examination she is tender in the right upper quadrant.
Bimanual vaginal exam reveals cervical excitation.
Urine dip shows leucocytes but is negative on a pregnancy test.
Bloods show a leucocytosis but are otherwise entirely normal.
What is the most likely diagnosis?
Fitz-Hugh Curtis syndrome
Fitz-Hugh Curtis syndrome is when pelvic inflammatory disease (PID) causes perihepatic inflammation, leading to RUQ pain and/or referred shoulder tip pain.
Chlamydia is the most common culprit. This lady had sexual intercourse with contraceptive cover but no condom, and so may have contracted a sexually transmitted infection which has gone unchecked.
PID is indicated here by the presence of cervical excitation.
High vaginal swabs can confirm the diagnosis.
Perihepatic fine adhesions may develop as a later complication.
Treatment is with antibiotics, commonly doxycycline or azithromycin.
What is Fitz-Hugh Curtis syndrome?
Fitz-Hugh Curtis syndrome is when pelvic inflammatory disease (PID) causes perihepatic inflammation, leading to RUQ pain and/or referred shoulder tip pain.
An 18 year old man visits the GP surgery. He has noticed multiple painful genital ulcers. He is otherwise well and reports this has not happened before.
He has no history of sexually transmitted infection
What is the most appropriate investigation in order to confirm the diagnosis?
Nucleic acid amplification test
This is now considered the most effective method for confirming HSV infection.
The presentation of multiple painful genital ulcers is synonymous with herpes simplex infection.
Ruling out other conditions informs future management and prognosis.
What is a Treponemal antibody screen?
This is an antibody screen that confirms syphilis infection.
A 40 year old man attends his GP with fever, malaise and a widespread maculopapular rash over his trunk, palms and soles.
This has developed over the past week.
He admits to having a painless penile ulcer that he first noticed 2 months ago but has since resolved.
He was given a dose of intramuscular benzathine penicillin.
Subsequently, he was brought into the Emergency Department with a high fever and rigors.
Observations show a
- temperature of 39 degrees Celsius
- respiratory rate of 16
- oxygen saturations of 97% on room air
- heart rate of 110 beats per minute
- blood pressure of 125/85
What is the most appropriate management?
What is the name of the reaction?
What causes it?
Reassurance and paracetamol
He displays signs of the Jarisch-Herxheimer reaction, which is an acute febrile reaction typically associated with the treatment of syphilis.
This is thought to be due to the sudden release of bacterial toxins from killed bacteria. It usually resolves within 24h and supportive management is sufficient.
A 67 year old homeless man presents to the Emergency Depratment after a sudden onset weakness of his right arm and leg.
He is currently alert but unable to recall the events leading up to his admission.
Neurological examination also reveals a positive Romberg’s sign, bilateral hyporeflexia of his lower limbs and upgoing plantars.
He has reduced vibration and joint position sensation of both lower limbs.
Cardiovascular examination reveals an early diastolic murmur loudest over the upper right sternal edge.
He has multiple hyperpigmented lesions on his shins with central necrosis.
What is the diagnosis?
Which investigation is most likely to confirm the underlying diagnosis?
Enzyme immunosorbent assay (ELISA)
This is the initial screening tool used for syphilis.
This patient has features of tertiary syphilis, as seen from his neurological signs (stroke, sensory ataxia, proprioceptive loss, mixed upper and lower motor neuron signs), cardiac signs (aortic regurgitation), cutaneous granulomas and dementia.
A 49 year old male presents to A&E with generalised weakness. He also reports difficulties initiating speech and swallowing. He is noted to be HIV positive and mentions his symptoms have come on progressively over two months. A whole brain CT scan is requested. The report states:
- There is a single lobulated lesion in the left frontal lobe, with solid homogenous enhancement. There is involvement of both the periventricular area and the caudate.
Further, to this, a stereotactic brain biopsy is requested. The report from this investigation states:
- There appears to be non-cohesive malignant lymphocytes present with reduced cytoplasmic volume. There is evidence of pleiomorphic nuclei and non-cohesion
Given the most likely diagnosis.
What is the most appropriate treatment? (2)
Commence cART and whole brain irradiation
The most likely diagnosis is Primary CNS lymphoma.
This is due to the progressive nature of the presentation, and the report of a single lobulated lesion with single homogenous enhancement.
This is further supported by a positive brain biopsy, demonstrating evidence of malignant lymphocyte proliferation.
In this case, cART is indicated along with whole brain irradiation
A 32-year old woman presents to clinic with a 4 day
history of vaginal pruritus and reports a white, curd-like vaginal discharge.
She is currently at 32-weeks gestation of her third pregnancy.
Given the likely diagnosis, which of the following is the most appropriate course of management?
Intravaginal clotrimazole
NICE recommend the use of intravaginal clotrimazole in the treatment of vaginal candidiasis in pregnancy
A 24 year old gentleman visits the GUM clinic.
Upon genital examination, he has a painless lesion on his penis. There is also evidence of a swollen inguinal ligament.
What is the most likely causative organism for this condition?
Chlamydia Trachomatis
The presentation in this instance is Lymphogranuloma Venereum (LGV).
This is a tropical disease, rare in the UK.
It classically presents with a non indurated lesion on his penis, and due to lymphatic destruction, it can cause a swollen inguinal ligament.
This is known as the Groove sign, with a groove visible above and below the inguinal ligament.
LGV is caused by Chlamydia, specifically serovars L1/L2/L3.
A 55 year old male presents to the Emergency Department with a 2 month history of a persistent dry cough and breathlessness that worsens when going up the stairs.
This has progressed to shortness of breath at rest over the past few days. Past medical history is relevant for a road traffic accident in rural Kenya, for which he had a splenectomy and blood transfusion.
He has no recent history of illness apart from an episode of flu-like symptoms and a widespread rash 6 months ago, which has since spontaneously resolved.
Observations show;
- temperature of 37.9 degrees Celsius
- respiratory rate of 30
- oxygen saturations of 86% on room air
- heart rate of 77 beats per minute
- blood pressure of 125/80
Arterial blood gas (ABG) showed
- pH 7.37
- PaO2 7.1 kPa
- PCO2 5.5 kPa
- HCO3 25 mmol/L
What is the most appropriate initial treatment? (2)
What is the diagnosis?
Co-trimoxazole and steroids
This is the best treatment for Pneumocystis pneumonia (PCP).
This is the most likely diagnosis given the progressive shortness of breath, exertional dyspnoea, and desaturation on ABG.
He is likely to have contracted HIV from a contaminated blood transfusion in rural Kenya, which explains the seroconversion illness he experienced 6 months ago.
Adjunctive steroids should be administered to patients with PaO2 ≤8 kPa and/or evidence of hypoxaemia e.g. oxygen saturations <92%.
This is to reduce mortality and risk of respiratory failure.
An 18 year old woman presents to the GUM clinic after having a coryzal illness for three days.
She then describes having some vulval tingling and is now complaining of three painful lesions that have appeared on her vulva.
What is the best advice to give the patient regarding ongoing sexual activity?
Sexual activity should be avoided until lesions are gone.
This is a classical description of a herpes simplex virus infection which manifests as genital ulcers. Typically, there is a viral prodrome which is followed by the appearance of painful ulcers on the genitals. The key piece of advice that needs to be given is that sex should be avoided when there is a prodrome and or genital lesions are present. Condoms and daily antivirals reduce transmission but cannot guarantee it. The only way to prevent transmission is to avoid all sexual contact until the lesions have disappeared.
A 24 year old lady presents to the GP surgery with vulval irritation.
She also explains that her vaginal discharge has changed recently.
It is now thick and white, she has not noticed a foul smell.
She is sexually active and she is on the mini pill so she does not use condoms with her partner.
What is the most likely diagnosis?
Thrush (vaginal candidiasis)
White discharge with some vulvovaginitis is a classic description of vaginal thrush
An 18 year old man presents to the GP. He describes multiple lesions on his penis.
On examination, there are multiple uniform smooth lesions present around the coronal margin of the glans.
Given the likely diagnosis, what is the most appropriate management?
Reassure and discharge
There is no treatment for pearly penile papules.
These are self limiting and the patient needs to be informed of this.
A 40 year old woman with increasing difficulty breathing and chest pain attends Accident and Emergency.
On auscultation, there is decreased air entry in the left lower lobe and late inspiratory crackles.
She has a past medical history of intravenous drug use.
She has markedly reduced exercise tolerance.
Oxygen saturation is 88% following a short walk around the ward.
What is the next best investigation for this patient?
HIV antibody and HIV antigen
This is the gold standard diagnostic test for suspected HIV and is a suitable option in this case. There is a strong suspicion of HIV, thus this is the most appropriate next investigation.
A 17 year old woman visits the GP.
She would like to begin taking hormonal contraception.
She reports that she currently uses barrier methods.
On questioning, she reports she experiences heavy and painful periods. There is no other relevant medical history.
Which of the following contraceptive methods is the most suitable for this patient?
COCP
This is the most suitable option and is recommended by the faculty of sexual and reproductive healthcare for patients who suffer from both heavy and painful periods.
A 35 year old male presents to the sexual health clinic with a painless penile ulcer that he first noticed 2 weeks ago.
He has had 5 casual partners in the last month and reports that he has sex with both men and women.
He reports having fever and malaise for the past few days.
Examination reveals bilateral tender groin swellings.
Which of the following is the most likely diagnosis?
Lymphogranuloma venereum (LGV)
This begins with a painless ulcer which progresses to form painful inguinal buboes, causing the characteristic “groove” sign.
This may be accompanied by fever and malaise.
Men who have sex with men (MSM) are at higher risk of LGV.
An 18 year old woman visits the GP clinic asking about different types of contraception. Previously she has been using barrier protection, but would like hormonal contraception.
She has a past medical history of epilepsy.
Of the following, what is the most appropriate contraceptive method to prescribe?
Contraceptive injection
The injection is the contraceptive of choice amongst the epileptic population. The injection does not interact with liver enzymes.
NOT THE COCP
A 22 year old woman visits the GUM clinic. She is asking about types of contraception. On questioning it is determined that she suffers from migraines that are associated with a preceding change in smell.
She also comments that she is against having an intra uterine device fitted and is currently using no contraception.
Given the clinical picture and patient preferences, what is the most appropriate contraceptive method to use?
POP
The current guidance stipulates that patients who suffer from migraines with aura should be offered the progesterone only pill is a suitable alternative.
A 35 year old Fijian man visits the GUM clinic.
He has noticed a small genital ulcer that is painless.
On genital examination, there is unilateral inguinal lymphadenopathy.
Given the likely diagnosis, what is the most appropriate management?
Doxycycline
In this instance, the diagnosis is Lymphogranuloma venereum (LGV). This is a clinical diagnosis, based on the existence of a small, single painless ulcer and unilateral lymphadenopathy. The specific serovars that cause LGV cause lymphatic destruction of the genital areas.
A 27 year old gentleman presents to the GUM clinic with a painful lesion on his penis. He has recently returned from a holiday in the Gambia.
Given the most likely diagnosis, what is the most appropriate management?
Chancroid presents with a painful ulcer on the penis.
It is common in the tropics, and a travel history should be explored if any patient presents with a painful lesion on their penis.
Given the travel history and the symptoms, a clinical diagnosis of Chancroid can be made.
Treatment involves Ciprofloxacin and Ceftriaxone
A 43 year old HIV positive man visits the GP complaining of a 2 day history of decreased visual acuity.
An examination of the fundus is carried out.
The fundus is described as containing spots within the retina, along with flame shaped haemorrhages.
What is the most appropriate management option for this patient?
Which infection does he have?
Intraocular Ganciclovir and PO Valganciclovir
Described in the stem is the typical ‘pizza pie retina’, associated with cytomegalovirus (CMV) infection. This is the correct management, with PO valganciclovir used to prevent systemic CMV spread
