Session 7: Group Work Flashcards
Colin aged 19, presents to you somewhat embarrassed. For the past two days he has experienced pain on passing urine, and a urethral discharge. He has no previous history of genital urinary problems and is normally fit and healthy. On examination he has no fever, discharge from his urethra is creamy, and there is a slight reddening of the surrounding glans penis.
What key things will you need to know about his history?
Sexual history
Contraception
Other symptoms
Urination
Smell of discharge
Color of discharge
What possible infections will you consider?
Chlamydia
Gonorrhoea
Non-gonococcal urethritis
You refer him to the local genito-urinary medicine clinic. A Gram stain intracellular shows Gram negative diplococci.
(ie. cocci in pairs).
3. What is your diagnosis now?
Gonorrhoea (Neisseria gonorrhoea)
What management will you consider?
Ceftriaxone and azithromycin. Double up to reduce risk of development of resistance.
Why do you think co- infections are common?
Engagement in risky behaviour.
You establish that Colin has a regular sexual partner, but she reports herself as well.
(ie. cocci in pairs).
6. Is it likely that she could be infected?
Yes, around 50% of women are asymptomatic.
- How would you manage her?
Screen, investigate. Treat if infected
Julie, aged 27 comes to see you. She has noticed a slight increase in vaginal discharge but is otherwise well. On questioning you establish that she had unprotected sex with a casual partner 5 days ago. She has no steady sexual partner.
- What differentials will you consider?
Pregnancy, chlamydia, gonorrhoea, trichomoniasis, Herpes (HSV-1 and 2) HIV, Bacterial vaginosis, vulvovaginal candidiasis, non-gonococcal urethritis, PID
- What investigations would be appropriate?
Vaginal swabs (high, vulvovaginal, endometrial)
Preg test
Vulval examination
PCR
NAAT
Viral serology
- Apart from offering her treatment with appropriate antibiotics, what other advice should you give her?
Tell her sexual partner. Avoid unprotected sex rn.
Julie attends A&E three weeks later with lower abdominal pain and fever.
- What differential diagnoses should be considered?
PID, Gonorrhoea, Ectopic pregnancy
- You suspect Pelvic Inflammatory Disease. What are the risk factors
associated with this condition?
Young age, multiple sex partners, no contraception, low socioeconomic status, infections like chlamydia and gonorrhoea, IUD.
How would you manage this condition (PID)?
Antibiotic for anaerobic organisms, doxycycline, ceftriaxone, azithromycin to cover any co-infection of chlamydia or gonorrhoea.
IV antibiotics in severe cases.
What potential complications could arise from ineffective treatment?
Ectopic pregnancy
Infertility
Fitz-Hugh-Curtis syndrome
Fixed retroverted uterus and chronic pelvic pain
You examine Julie and find that she is tender in the right upper quadrant of her abdomen.
- What anatomical structures will you be considering as the reasons
for this tenderness?
Liver, diaphragm, stomach lining
- How might tenderness in these structures be linked to her other
symptoms?
Chlamydial PID can lead to Fitz-Hugh-Curtis syndrome with peri-hepatitis which is inflammation of the liver capsule. This is an ascending infection starting in vagina and working its way up. Fallopian tube into peritoneal cavity.
Helena went to the GP a few weeks ago to discuss contraceptive options and decided to start taking the combined oral contraceptive pill. She has come to you now because she has developed genital itching and white discharge.
What organism(s) will you consider in this case?
Candida albicans.
Why might the organism have grown at this particular time?
Because COCP contains oestrogen and oestrogen favours yeast growth.
- What conditions in the vagina will promote its growth?
Glucose (diabetes), glycogen (low lactobacilli), oestrogen etc…
- What are the principles of treatment of this condition?
Education about COCP
Azoles (antifungal) either oral or topical.
- Does vulvovaginal candidiasis count as an STI?
No.
Jane, aged 18, presents with a two day history of painful genital ulcers, mild fevers and a painful swelling in her left groin. During the past few hours she has experienced marked dysuria.
What other aspects of the history are you going to seek?
Sexual history
Other symptoms
Contraception
Discharge
Cold-sores
- What are the most likely aetiological agents?
Herpes simplex virus 1 or 2. 2 more likely
- How would you confirm the diagnosis?
Swabs
Serology
PCRs
NAATs
- How would you manage her illness?
Acyclovir
