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Flashcards in Week 5 - Vaginal discharge Deck (17)
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1

M.S. 25 year old female. She says that she has something wrong ‘down there’.

Take a history of this patient.

HPC:
• Vaginal discharge, vulval itch, 2wk, not offensive, ‘cheesy’.
- What are the different types of discharge - cheesy, clear, pus, blood etc.
• Vulva feels ‘sore and tingly’ as well as itchy… never had before menarche at 11 years* on OCP, brief periods regular*
• Forgets pill* - at least 1 or 2 a month. Has tried Implanon*
• Sexual history many relationships* smokes socially*, alcohol* no drugs
• Post coital bleeding - no*, cervical smear? Never*
- Post coital bleeding important - suggestive of cervical cancer.
• Asthma and many ear infections as child*, Grommets* x2
• Dysuria taking ural* Had Gardasil* at school.
• Tender suprapubic, inflamed vulva, introitus, vagina, Cx.
• White patches*, ulcers* vagina and vulva, cervicitis. LN+*
- Inguinal lymph nodes positive.

• Symptoms are worsening. Taking regular panadeine.
• LMP 3 weeks previously.
• Cycle usually every 4 weeks “because I am on the pill”. Usually remembers to take the pill but forgets 1 or 2 tablets per month.
• Previously periods had been every 4-6 weeks. Has previously tried implanon but periods were very irregular on implanon.
• No intermenstrual bleeding or bleeding after intercourse.
• Sexual history - 3 new partners over the last 6 months. Does not always use condoms - ‘oh sometimes’
• Some dysuria over the past 1 week.
• Has been getting up once at night to pass urine. No urinary frequency or fevers.
• PMHx - grommets as a child.
• Immunisations - childhood vaccinations up to date and has received Gardasil at school.

HPC:
• Site of discharge.
• Onset.
• Character - colour, odour, consistency, volume.
• Alleviating factors.
• Experienced discharge before? Constant/intermittent? Episodes? Worse at a particular time?
• Exacerbating factors.
• Severity.
• Associated symptoms i.e. pain, bleeding.

STI
• Partners
- Number, gender, length of relationship. Ask about partner’s risk factors such as current/past sex partners or drug use.
- Are you currently sexually active?
- In recent months, how many sex partners have you had?
- In the past 12 months, how many sex partners have you had?
- Are your sex partners men, women or both?

• Practices
- I am going to be more explicit here about the kind of sex you’ve had over the last 12 months to better understand if you are at risk for STDs.
- What kind of sexual contact do you have or have you had? Genital (penis in the vagina)? Anal (penis in the anus)? Oral (mouth on penis, vagina or anus)?

• Protection from STDs
- Do you and your partner(s) use any protection against STDs? If not, could you tell me the reason?
- If so, what kind of protection do you use?
- How often do you use this protection?
- If ‘sometimes,’ in what situations or whom do you use protection?
- Do you have any other questions or are there other forms of protection from STDs that you would like to discuss today?

• Past history of STDs
- Have you even been diagnosed with an STD? When? How were you treated?
- Have you had any recurring symptoms or diagnoses?
- Have you even been tested for HIV, or other STDs? Would you like to be tested?
- Has your current partner or any former partners ever been diagnosed or treated for an STD? Were you tested for the same STD(s)?
- If yes, when were you tested? What was the diagnosis? How was it treated?

• Prevention of pregnancy
- Are you currently trying to conceive or father a child?
- Are you concerned about getting pregnant or getting your partner pregnant?
- Are you using contraception or practicing any form of birth control? Do you need any information on birth control?

• What other things about your sexual health and sexual practices should we discuss to help ensure your good health?
• What other concerns or questions regarding your sexual health or sexual practices would you like to discuss?

UTI
• Dysuria, frequency, urgency, nocturia, haematuria, suprapubic pain.
• Fever, abdominal pain/loin tenderness, foul-smelling urine.

PID
• Pain in pelvis, abdomen, lower back, vagina.
• Pain during intercourse/on urination.
• Chills, fatigue, fever. Nausea or vomiting.
• Vaginal discharge/odour.
• Cramping or painful menstruation.

• Intermenstural or post coital bleeding?

PMHx:
• Past medical history of STI, UTI etc.
• Menstrual history - LMP, regular?

PSHx:
• Any recent surgeries?

Medications:
• Any regular medications? i.e. OCP

Allergies:
• Agent, reaction, treatment.

Immunisations/screening:
• E.g. Fluvax, pneumococcal.
• When was last pap smear/mammogram? Abnormal?

FHx:
• Any family history of STI, UTI, PID etc.

SHx:
• Background
• Occupation
• Education
• Religion
• Living Arrangements
• Smoking
• Nutrition
• Alcohol/recreational drugs
• Physical activity

Systems Review:
• General - weight change, fever, chills, night sweats?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea, cough, sputum or wheeze?
• GI - vomiting, diarrhoea, indigestion, dysphagia, change in bowel habit, abdominal pain?
• UG - dysuria, polyuria, nocturia, urgency, incontinence, urine output?
• CNS - heachaches, nausea, trouble with hearing or vision?
• ENDO - heat/cold intolerance, swelling in throat/neck, polydipsia or polyphagia?
• HAEM - easy bruising, lumps in axilla, neck or groin?
• MSK - painful or stiff joints, muscle aches or rash?

2

Which of the following organisms would you consider to be the 3 most common which would cause her symptoms after taking her history?
• Candida Albicans.
• HIV.
• Chlamydia/Gonorrhoea.
• Trichomonas vaginalis.
• Gardnerella vaginalis.

• Candidia albicans - classically white thick discharge.
• Chlamydia/Gonorrhoea - possibly - important to consider that these infections may also be asymptomatic.
• Trichomonas vaginalis - usually sexually transmitted. Classically vulval soreness and itching. Foul smelling discharge - green/yellow in colour. Strawberry cervix is classical on examination with the speculum - this is due to punctuate haemorrhages.

• Gardnerella vaginalis - common condition causing foul/fishy smelling vaginal discharge. Gardnerella may be cultured from patients who are symptomatic. It is associated with a reduction in the numbers of lacto bacilli in the vagina.

3

Perform a physical examination on this patient.

Introduction:
• Wash hands.
• Name, patient preferred name.
• Explain procedure - pelvic exam 3 parts.
• Any questions?
• Any pain or discomfort - can stop at any time?
- May be some discomfort at some stages of the examination but I will warn you before and let me know if you would like to me to stop.
• Verbal consent.
• Ask patient if they need to go to bathroom - empty bladder.
• Ask patient if they would like a chaperone.

Pelvic exam - 3 parts
• Prepare for pap smear - open speculum and lube. Wash hands and glove. Ask patient to raise heel towards their bottom and place speculum and bluey on end of bed. Pick up speculum and apply lube (proximal end, not tips if doing pap smear). Ask patient to remove drape to stomach and relax knees apart.
1. Inspection
• Inspect external genitalia

2. Speculum insertion to see cervix/take sample
• Tap thigh first.
• Spread labia - lower down
• Insert speculum all the way, open lever, close lock. Never remove hand from handle.
• Obtain specimens. First one 3-5 times clockwise, second one enter cervical os to halfway and rotate once. Smear each sample on slide and fix with spray. Close slide.
• Both fingers on handle and lever, unlock and remove first 5mm. Then remove one finger and release lever. Remove speculum slowly.

3. Bimanual - 2 gloved fingers/palpation
• Apply additional lube to fingers.
• Tap thigh first.
• Spread labia - lower down.
• Insert fingers and apply upwards pressure on cervix. Palpate with ulnar edge down stomach feeling for fundus.
• Move fingers laterally to either side of cervix (fornices) and palpate abdomen for ovaries.
• Remove fingers, give patient tissues and ask them to cover up/get dressed.

4

Perform a physical examination on this patient.

• Stable observations. Looks uncomfortable, pale.
• Abdomen soft and slightly tender suprapubically.
• No guarding or rebound.
• No masses or organomegaly.
• Marked inguinal lymphadenopathy.
• Vulva redden, thick white discharge.
• Speculum - very tender white discharge see on vaginal walls. No erosions or erosions seen bimanual examination.
• Uterus and adenexae non tender.

Introduction:
• Wash hands.
• Name, patient preferred name.
• Explain procedure - pelvic exam 3 parts.
• Any questions?
• Any pain or discomfort - can stop at any time?
- May be some discomfort at some stages of the examination but I will warn you before and let me know if you would like to me to stop.
• Verbal consent.
• Ask patient if they need to go to bathroom - empty bladder.
• Ask patient if they would like a chaperone.

Pelvic exam - 3 parts
• Prepare for pap smear - open speculum and lube. Wash hands and glove. Ask patient to raise heel towards their bottom and place speculum and bluey on end of bed. Pick up speculum and apply lube (proximal end, not tips if doing pap smear). Ask patient to remove drape to stomach and relax knees apart.
1. Inspection
• Inspect external genitalia

2. Speculum insertion to see cervix/take sample
• Tap thigh first.
• Spread labia - lower down
• Insert speculum all the way, open lever, close lock. Never remove hand from handle.
• Obtain specimens. First one 3-5 times clockwise, second one enter cervical os to halfway and rotate once. Smear each sample on slide and fix with spray. Close slide.
• Both fingers on handle and lever, unlock and remove first 5mm. Then remove one finger and release lever. Remove speculum slowly.

3. Bimanual - 2 gloved fingers/palpation
• Apply additional lube to fingers.
• Tap thigh first.
• Spread labia - lower down.
• Insert fingers and apply upwards pressure on cervix. Palpate with ulnar edge down stomach feeling for fundus.
• Move fingers laterally to either side of cervix (fornices) and palpate abdomen for ovaries.
• Remove fingers, give patient tissues and ask them to cover up/get dressed.

5

What is your provisional and differential diagnoses?

• Provisional diagnosis: STI
- Herpes type 1 - in this age group may well be the most likely cause. 70% of genital herpes in this age group is due to type 1.
- Herpes type 2.
- Candida - thick white discharge.
- Chlamydia - possible.
• DDx:
- UTI
- PID
- Pregnancy (ethics, confidentiality, clinical examination of STI, crime).

6

What investigations would you carry out on this patient?

• Urine beta-HCG.
• Vaginal swab.
• Endocervical swab.
• Cervical smear.
• Urine MC+S.
• VDRL (Venereal Disease Research Laboratory) - blood test for syphilis - detects antibody present in bloodstream.
• Hepatitis serology.
• HIV serology.
• Viral swab lesion.

7

What investigations would you prioritise today?

• HVS (high vaginal swab) - for culture/NAAT of causes of vaginosis (gardnerella usually a clinical diagnosis) and vaginitis - candida, trichomonas.
• Endocervical swab - for culture/NAAT of chlamydia and gonorrhoea.
• Swab of lesions for PCR testing - this is the most reliable test for genital herpes.

8

Results:
• HVS positive for candida albicans.
• Herpes simplex type 1 on viral swab of lesions.

How would you treat her herpes infection?

How would you manage her vaginal candida?

Herpes:
• Pain relief - panadeine forte/NSAIDs if no contraindications.
• Oral antivirals.
• Contract tracing.
• Education regarding infectivity - condoms may not always protect and not to have sex when has lesions.

Vaginal Candida:
• Topical antifungal - clotrimazole (available over the counter).
• Oral fluconazole may be indicated for recurrent infection.

9

She returns for follow up and is reluctant for a pap smear. ‘I had my Gardasil at school I don’t need a pap smear.

What do you tell her? What is your advice regarding the screening interval? How is follow up arranged? Gardasil is an effective vaccine for which types of HPV?

• It is important that women aged between 18-69 years continue to have Pap smears every two years and talk to their doctor or health care professional if they have any questions.
• Gardasil - quadrivalent vaccine against strains 6, 11 (wart) and 16, 18 (Ca) of the HPV virus.

10

Her pap result is reported as LSIL-low grade squamous intraepithelial lesion. What follow up is advised? How do you explain this to the patient?

• LSIL and <30yo → repeat pap smear at 12 months.
- If negative → repeat pap at 12 months → negative (results fluctuate) → routine screening.
- If LSIL (definite/possible) → colposcopy.

11

List the pertinent questions relevant to sexual history taking.

• GP STI Testing Tool 2012
• Partners
• Prevention of Pregnancy
• Protection from STDs
• Practices
• Past History of STDs

12

A 22 year old female is admitted with symptoms and sign of PID. Her investigations confirm gonorrhea as the cause. Which of the following is the most likely complication of her condition?

A. Chronic pelvic pain.
B. Ectopic pregnancy.
C. Endometriosis.
D. Liver failure.
E. Abdominal abscess

Chronic pelvic pain.

13

A 30 year old woman is worried because she has marked vaginal irritation. Which of the following is likely to be the most common cause of a vaginal itch in this woman?

A. Candida Albicans.
B. Candida Glabrata.
C. Lichen sclerosis.
D. Lichen planus.
E. Psoraisis.

Candida Albicans.

14

A 30 year old woman is married with 2 children presents with a yellow/cream vaginal discharge and a vulval irritation over the previous 3 days. On examination there is marked erythema of the vulva with a thick discharge noted. The cervix has a strawberry like appearance.

A. C albicans.
B. Chlamydia.
C. Bacterial vaginosis.
D. Trichomonas.
E. Gonorrhoea.
F. Cervical erosion.
G. Physiological.
H. Atrophic vaginitis.
I. Acute endometritis.

Trichomonas.

15

A 22 year old woman who is 12 weeks pregnant presents with a thick white discharge and vaginal itch. Her vulva is erythematous.

A. C albicans.
B. Chlamydia.
C. Bacterial vaginosis.
D. Trichomonas.
E. Gonorrhoea.
F. Cervical erosion.
G. Physiological.
H. Atrophic vaginitis.
I. Acute endometritis.

C albicans.

16

A 28 year old woman has an increase in vaginal discharge mid cycle. There is no odour.

A. C albicans.
B. Chlamydia.
C. Bacterial vaginosis.
D. Trichomonas.
E. Gonorrhoea.
F. Cervical erosion.
G. Physiological.
H. Atrophic vaginitis.
I. Acute endometritis.

Physiological.

17

A 26 year old female presents with high fevers and a purulent discharge 3 weeks post partum. This can be associated with uterine instrumentation or with retention of placenta after vaginal or caesarean section.

A. C albicans.
B. Chlamydia.
C. Bacterial vaginosis.
D. Trichomonas.
E. Gonorrhoea.
F. Cervical erosion.
G. Physiological.
H. Atrophic vaginitis.
I. Acute endometritis.

Acute endometritis.