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109 Cards in this Set
- Front
- Back
What is the normal colour of physiological discharge?
What is the normal colour, consistency and volume (increased or decreased) of it at ovulation? |
Milky-white/clear.
At ovulation, it becomes thinner, clearer and increased in volume. |
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What does OCP/HRT do to physiological discharge?
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Increases it.
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Does physiological discharge increase or decrease with pregnancy?
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Increase.
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What routine investigations are done for a PV discharge?
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- High vaginal swab (posterior fornix) for Group B streptococcus, candida, trichomonas, and BV.
- Endocervical swab for GC and chlamydia PCR. - Endocervical MCS swab for MCS if GC/endometritis suspected. |
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When investigating using a high vaginal swab (posterior fornix), what organisms would you be looking for?
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- Group B streptococcus.
- Candida albicans. - Trichomonas vaginalis. - BV. |
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When doing an endocervical swab, what would you be looking for with PV discharge?
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- GC.
- Chlamydia. - MCS if GC/endometritis suspected (in this case, an endocervical MCS swab is required). |
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What investigations would you do for dysuria?
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- Urethral swab or first swab urine for chlamydia & GC PCR.
- Mid-stream urine for MCS. |
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What investigations would you do for oral/rectal symptoms?
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Oropharyngeal/rectal swab for MCS.
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If a female patient has vesicals/genital ulcers, what should you perform investigation-wise?
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- Swab for herpes culture or HSV antigen detection (HSV1, 2, zoster).
- Serology - for syphilis, lymphgranuloma, venereum, Hep B, HIV. |
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If a female patient has vesicals/genital ulcers, what organisms are looked for in the serology?
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- Syphilis.
- Lymphgranuloma. - Venereum. - Hepatitis B. - HIV. |
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What is monilia vulvitis?
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Oedema and inflammation of the external genitalia (due to candida).
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Is candida (monilia) infection an STI?
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No, it's not considered an STI. Candida is endogenous.
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What are the main organisms responsible for candidiasis?
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- Candida albicans (90%).
- Candida glabrata (5-10%). - Other yeasts. |
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What percentage of infective vaginitis comprise of candida?
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20-30%.
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What are the main symptoms of candidiasis?
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- Mild to intense vulvovaginal itch - worse at night, warmth.
- Vulval soreness. - Discomfort with sex. |
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What are the signs you look for during examination with candidiasis?
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- Vulvovaginal erythema/excoriation/oedema.
- White curd-like discharge (may be thin). - Adherent plaques. |
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What are the predisposing features of candida overgrowth?
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- Immunosuppression (AIDS, pregnancy, debilitating illness, immunosuppressants).
- Diabetes. - OCP. - Antibiotics. - Humidity/bathing suit/nylon or tight underwear. - (Male resevoir - Balanitis). |
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What can you use to treat candida?
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Topical imidazoles - works in the majority of cases. (Clotrimazole, miconazole, econazole, nystatin).
If resistant: - Fluconazole OR - Ketoconazole. - Candida glabrata Boric acid. |
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What are the different types of 1st-line topical imidazoles (used for candida)?
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- Clotrimazole (cream or pessary).
- Miconazole cream/pessary. - Econazole pessary. - Nysatin pessary. |
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Do you need to treat the male partner of a female patient diagnosed with candidiasis?
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No, unless symptomatic.
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Is bacterial vaginosis considered an STI?
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No.
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What are the main organisms responsible for bacterial vaginosis?
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- Gardnerella vaginalis.
- Mobiluncus spp. - Anaerobes. - Mycoplasma hominis. |
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What percentage of infective vaginitis is due to bacterial vaginosis?
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40-50%.
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In bacterial vaginosis, around what pH value is the vaginal discharge?
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The pH would be above >4.5
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What are clue cells and which infective vaginitis is it most likely to be indicative of?
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Clue cells are a result of small coccobacilli attaching to vaginal squamous cells. It is indicative of bacterial vaginosis.
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What are the signs and symptoms of bacterial vaginosis?
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- Grey, watery profuse discharge (non-adherent).
- Malodorous (fishy) smell, especially after sex or menses. - Usually no/minimal irritation or dyspareunia. - No obvious vulvovaginitis. |
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The malodorous smell of bacterial vaginosis is particularly bad at what times?
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After sex and menses.
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What is the treatment for bacterial vaginosis?
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50% are asymptomatic and require no treatment.
The symptomatic cases can be treated by 1 of the following: - Metronidazole 400mg with food for 7 days. - Clindamycin 2% vaginal cream PV daily or 300mg tablets bd - for 7 days (preferred treatment if pregnant). - A single dose of 2g of tinidazole or metronidazole may be used but lower cure rate and Re-Rx may be needed. |
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Strawberry spots are indicative of what cause of infective vaginitis?
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Trichomonas vaginalis.
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What kind of infection is trichomonas?
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Protozoal.
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Trichomonas commonly coexists with what other problem?
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Bacterial vaginosis.
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Is trichomonas an STI?
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Yes.
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What are the signs and symptoms of trichomonas infection?
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- Irritating, yellow-green profuse thin discharge (bubbly in 20-30%).
- Pruritis and dyspareunia. - Malodorous (fishy) discharge. - 50% asymptomatic. - Vulvovaginitis. - Characteristic punctate appearance of colpitus macularis - erythematous. |
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What percentage of trichomonas infection is asymptomatic?
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50%.
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What is the treatment of trichomonas?
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- Check for other STIs.
- Treat the partner as well! Choose one of the following: - Tinidazole 2g single dose with food. - Metronidazole 2g single with food. - If relapse, metronidazole 400mg bd for 5 days. |
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If a pregnant patient has trichomonas, what could be used to treat her?
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Metronidazole 2g single dose with food.
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What is the most notified of all STIs in QLD?
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Chlamydia trachomatis.
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The majority of Chlamydia notifications occur in what age group?
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15-24 years old (60% of notifications).
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What are the signs and symptoms of chlamydia trachomatis infection?
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50% asymptomatic.
Early symptoms may include: - Mucopurulent discharge (from endocervical canal). - Dysuria (co-existing urethral infection). 10-15% are complicated by PID. Inflamed, oedematous and friable ectropion with contact bleeding. |
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Chlamydia infection is asymptomatic in what percentage of the infected?
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50%.
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What percentage of cases of chlamydial infection results in a PID complication?
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10-15%.
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What patients should be tested for chlamydia?
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- Known sexual contact with somebody with STI/chlamydia.
- Symptomatic. - Where there has been unprotected intercourse and one or more of the following: = Change of sexual partner in 2 months. = >1 sexual partner. = Patient's partner has had other sexual partners. - Patient < 25 years old and has had unprotected intercourse. - Patient has an IUCD in situ, and any of the above factors exist. |
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How do you treat chlamydial infection?
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Either:
- Azithromycin 1g orally once. - Doxycycline 100mg bd for 7 days. Treat the partner as well. |
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Gonococcal infection can result where and what reaction?
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- Gonococcal urethral discharge.
- Gonococcal pharyngitis. - Gonococcal rectal inflammation. - Gonococcal epididymitis and sympathetic hydrocoele. - Ophthalmia neonatorum. |
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Describe the structure of the gonorrhoea organism.
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Gram negative intracellular diplococcus.
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What cells does gonorrhoea infect?
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Columnar and transitional epithelium.
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What are the primary sites of infection of gonorrhoea?
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Mucous membranes of the:
- Urethra. - Endocervix. - Rectum. - Pharynx. |
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How is gonorrhoea transmitted?
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- Direct sexual contact and mutual masturbation.
- Conjunctival infection via perinatal transmission and sometimes via adults with poor hygiene who auto-inoculate their eyes unwittingly after handling their genitals when going to the toilet. |
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What is the infection rate of gonorrhoea from a single exposure?
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60-90%.
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What is the usual incubation period of gonorrhoea?
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2-7 days - may be longer.
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Gonorrhoea is potentially communicable for _____ if untreated. (Days, Weeks, Months or Years?)
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Months. However, once treated, communicability ends within hours.
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What percentage of cases of Gonorrhoea complicated with PID?
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10-15%.
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What are the signs and symptoms for gonorrhoea infection in a woman?
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Few symptoms and signs in women. For those who do have symptoms:
- Majority have endocervicitis - inflamed cervix with mucopurulent discharge. - 70-90% urethritis. - Ascending infection --> PID |
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Gonorrhoea infection commonly occurs with a coexistent...
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Infection with chlamydial trachomatis.
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What complications can occur with PID?
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- Ectopic pregnancy.
- Infertility. - Chronic pelvic pain. |
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What is the treatment for gonorrhoea?
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- Ceftriaxone 250mg IMI once
AND - Followed immediately by anti-chlamydial treatment azithromycin 1g orally or doxycyline 100mg bd orally for 7 days. Treat partners. Perform follow-up cultures. |
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What pathological features occur with cervicitis?
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- Mucopurulent discharge from endocervical canal.
- Inflamed oedematous friable ectropion with easy contact bleeding. |
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What are the most likely causes of cervicitis?
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Gonorrhoea or chlamydia.
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In cases of endocervicitis, what should you do in terms of investigations?
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Take endocervical swabs for chlamydia, gonorrhoea and gram staining.
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What is the treatment for a NON-STI related, mild-to-moderate case of pelvic inflammatory disease?
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Mild to moderate:
- Doxycycline 100mg bd for 2-4 weeks. OR - Amoxycillin 500mg tds PO PLUS metronidazole 400mg tds PO for 2-4 weeks. |
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What is the treatment for a NON-STI related, SEVERE case of pelvic inflammatory disease?
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Amoxycillin IV plus gentamicin IV plus metronidazole IV...
THEN: Doxycycline PO for 2 weeks. |
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What is the treatment for a STI-related mild-to-moderate case of pelvic inflammatory disease?
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- Azithromycin PLUS
- Ceftriaxone IM OR ciprofloxacin PLUS - Doxycycline PLUS - Metronidazole. |
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What is the treatment for a STI related SEVERE case of pelvic inflammatory disease?
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- Cefotaxime OR ceftriaxone OR cefoxitin IV
PLUS - Metronidazole IV PLUS - Doxycycline or roxithromycin PO until afebrile THEN continue oral doxycycline or roxithromycin for 2-4 weeks. |
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Who are at special risk for STIs?
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- Homeless people.
- Young people. - Sex workers. - Prisoners. - People returning from overseas. |
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Who may have poorer access to treatment for STIs?
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- People with a disability.
- Victims of sexual violence. - People from low SES background or from marginalised communities. - People from NESB. - People living in rural or remote communities. |
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What are the main vaginal causes for PV discharge?
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- Candida.
- Trichomonas. - Gardnerella (bacterial vaginosis). - Atrophic vaginitis. - Other e.g. retained foreign body, tumour. |
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Explain the pathology underlying atrophic vaginitis.
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Reduced vaginal acidity and thin bacterial walls allowing bacterial attack.
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What are the signs and symptoms of atrophic vaginitis?
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- Yellowish, non-offensive discharge.
- +/- post-coital bleeding or spotting. - Reddened vagina. - Tenderness and dyspareunia. |
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What is the mainstay of treatment of atrophic vaginitis?
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HRT (oral or topical).
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What are the cervical causes of PV discharge?
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- Gonorrhoea.
- Chlamydia. - Non-specific genital infection. - Herpes. - Cervical atrophy. - Cervical neoplasm - polyp. |
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What is the probability diagnosis of vaginal discharge?
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Normal physiological discharge.
Vaginitis: - Bacterial vaginosis 40-50%. - Candidiasis 20-30%. - Trichomonas 10-20%. |
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What are the serious disorders not to be missed with vaginal discharge?
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- Neoplasia (carcinoma, fistulae).
- STIs/PID - chlamydia, gonorrhoea. - Sexual abuse, especially in children. - Tampon toxic shock syndrome (staph infection). |
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What are the pitfalls for vaginal discharge?
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- Chemical vaginitis e.g. perfume.
- Retained foreign object e.g. tampons. - Endometriosis (brownish discharge). - Ectopic pregnancy ('prune juice' discharge). - Poor toilet hygiene. - Genital herpes (possible). - Atrophic vaginitis. |
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Which of the 7 masquerades may cause vaginal discharge?
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- Diabetes.
- Drugs. - UTI. |
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Vaginal discharge...is the patient trying to tell us something?
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Consider:
- Possible sexual dysfunction. - Possible sexual abuse. - Possible anxiety/stress. - Possible relationship problems. - Other concerns: cancer. |
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What percentage of cervical cancer can be prevented with cervical screening of asymptomatic individuals?
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90%.
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Hwo frequently should women have cervical screening?
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Every 2 years.
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Who should have cervical screening?
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All women ever sexually active - to commence between 18-20 years of age.
OR 2 years after 1st intercourse. (Whichever is later). Women over 70 should also be screened if they request a smear or if they have never had a smear. |
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At what age can a woman stop cervical screening?
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70 years.
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What are the risk factors for cervical cancer?
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- Any woman who has been sexually active and who has not had a hysterectomy.
- First sexual intercourse at an early age. - A number of sexual partners, or a sexual partner who has a number of other partners. - Cigarette smoking. - Certain strains of HPV - especially genotypes 16 & 18. - Daughters of women who took diethylstilboestrol (DES). - Low SES. - Indigenous race. |
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On a PAP smear test, the PAP result is 'Unsatisfactory PAP'. What course of action should be taken?
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Repeat the test in 6-12 weeks.
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What does LSIL stand for?
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Low grade squamous epithelial lesion.
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The PAP smear result:
Index PAP = LSIL (possible or definite). What course of action should be taken? |
Repeat PAP smear in 12 months.
Further action after this second smear: - Normal - repeat PAP 12 months. - LSIL - colposcopy. - HSIL - colposcopy. If 2 LSIL results within 3 years (even if also a normal Pap), do a colposcopy. |
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The PAP smear result:
Index PAP = LSIL (possible or definite). The repeated test done 12 months later was normal. What course of action should be taken? |
Repeat PAP smear in 12 months.
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The PAP smear result:
Index PAP = LSIL (possible or definite). The repeated PAP smear 12 months later resulted in LSIL. What course of action should be taken? |
Colposcopy.
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The PAP smear result:
Index PAP = LSIL (possible or definite). The repeated PAP smear 12 months later resulted in HSIL. What course of action should be taken? |
Colposcopy.
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If the PAP smear showed 2 LSIL results within 3 years, what course of action should be taken?
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Colposcopy.
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If a colposcopy for LSIL results in an 'Unsatisfactory Result', what action should be taken?
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Repeat PAP in 6-12 months.
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If a colposcopy for LSIL results in a 'Normal Result', what action should be taken?
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Yearly PAPs until 2 normal smears, then routine screening.
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If a colposcopy for LSIL results in an ' LSIL Result', what action should be taken?
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Biopsy --> Confirmed LSIL --> Repeat PAP @ 12 and 24 months.
If both PAPs are normal, then routine screening. If either PAP LSIL --> Annual smears until at least 2 negative, then routine screening. |
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If an Index PAP smear results in a HSIL (possible or definite), what action should be taken?
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Refer for colposcopy and biopsy.
If histology = CIN2 or CIN3, then it needs treatment. |
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What HSIL CIN levels indicate a need for treatment?
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CIN2 or CIN3.
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If the PAP result indicates 'HSIL with invasive features' what course of action needs to be taken?
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Refer to gynae with malignancy expertise, within 2 weeks.
After treatment for HSIL: - Colposcopy + PAP at 4-6 months. - PAP and HPV typing at 12 months. - Then annual PAPs until 2 consecutive negative Paps, then routine screening. |
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What Pap smear results require immediate referral to gynaecologist with expertise in malignancy?
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- Adenocarcinoma.
- Endocervical adenocarcinoma in situ (AIS). - Possible high-grade glandular lesions. |
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Screening for HPV involves what process?
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HPV DNA testing.
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What significance does the HPV vaccine have for women's health?
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Prevention of HPV diseases including:
- Cervical cancers. - Precancerous lesions. - Genital warts. |
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Gardasil is a quadrivalent HPV recombinant vaccine protective against which HPV types?
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6, 11, 16, 18.
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How is Gardasil vaccination done?
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3 doses IM over 6 months.
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Cervarix is a HPV bivalent recombinant vaccine protective against which HPV types?
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16,18.
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What groups are recommended to have Gardasil vaccination?
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Females 9-26 years.
Males 9-15 years. |
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The Australian government is giving free HPV vaccines to what population?
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Females 12-26 years of age.
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Suggested open ended
questions for taking a sexual history. |
• Why do you think you have been at risk of STIs or HIV?
• Which STIs are you particularly concerned about? • What do you think I need to know about your sexual practises to ensure that I order the best tests? • What do you do to protect yourself against HIV infection and other STIs? • In what situations would you be less likely to use condoms? • Tell me about your use of condoms, for anal sex, vaginal sex, oral sex? |
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STI Screening asymptomatic individuals at risk through noncommercial sexual
activity. What populations and patients would you screen? |
• Anyone who asks for a test.
• Contact of anyone with an STI. • Young sexually active people under 25 years of age (chlamydia especially). • Unprotected sex (especially overseas country of higher HIV risk). • Multipartnered individuals. • Recent change in sexual partner. |
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What STIs can be checked with a routine blood test?
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- HIV.
- Hep B. - Syphilis. - Hep C (not usually sexually transmitted - but if blood to blood transmission possible). |
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What STIs can you check for in the urine?
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- Chlamydia.
- Gonorrhoea. |
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What is the risk of HCV transmission through sexual contact?
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Risk of HCV transmission via sexual contact is low, estimated at up to 0.6% per year in monogamous relationships and up to 1.8% per year in those with multiple partners.
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What is the most common notifiable bacterial infection in Australia?
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Chlamydia.
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What percentage of sexually active adults have been infected with HPV?
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50%.
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What is the prevalence of HSV1 and HSV2?
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HSV-2 is common (15–30%) and HSV-1 infection, usually acquired orally before the age of 15 years, is very common (75–80%).
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