01-07-2004, 10:25 AM
TUN
Trichomonas vaginitis
(36 y/o F with purulent, malodourous, thin, greenish frothy vaginal discharge with burning, pruritis, dysuria and dyspareunia).
Location
Office
P/Exam
Abdomen
Pelvic
Extremities
Results
Erythema of vulva and vagina; punctate hemorrhages may be seen
Order
Vaginal pH,stat
Wet mount prep (saline and KOH),stat
Gram stain of the discharge
PAP smear, routine
GC cervical culture
Chlamydia, cervical culture
CBC with diff.,routine
U/A, routine
beta-HCG
If high risk sexual behaviour-----> order VDRL, HIV screen and Hepatitis B.
Results
(pH > 4.5----> bacterial vaginosis or trichomonas)
(wet mount----> motile trichomonads seen
Order
Non pregnant---> metronidazole 500mg BID x 7 days or 2gm single dose.
Pregnant----> 1st trimester, Clindamycin cream; 2nd and 3rd trimester, metro.
No alcohol(atleast 48 hrs)--> antabuse effect with metro.
Rx the partner
Send pt. home.
Schedule appt. after 1 week.
Pt. feeling better with no more symptoms.
After the 5 min. screen comes up:
Order
PT. education
Safe sex
Councel, no alcohol
Councel, no smoking
PAP smear annually
No recreational drugs
Age appropriate screening tests and immunizations (e.g,annual mammogram >50 yrs; annual fecal occult blood test and colonoscopy x 10 y > 50 y).
Primary DX
Trichomonas vaginitis
=======================================
Bacterial vaginosis
(36 y/o F with h/o fishy smelling vaginal discharge after unprotected intercourse).
Location
Office
P/Exam
Abdomen
Pelvic
Extremities
Order
Vaginal pH,stat
Wet mount prep (saline and KOH),stat
Gram stain of the discharge
PAP smear, routine
GC culture
Chlamydia, culture
CBC with diff.,routine
U/A, routine
beta-hcg, routine
Results
(pH > 4.5----> bacterial vaginosis or trichomonas)
(wet mount----> clue cells (epithelial cells studded with bacteria on saline wet mount and + whiff-amine test --> fishy odour when 10% KOH is added to the discarge; no inflammatory cells on gram stain).
Order
Metronidazole 500mg BID PO x 7 days
Metronidazole gel x 5days (as effective as oral metro.)
(no need to Rx the partner)
Send pt. home.
Schedule appt. after a week.
Pt. feeling better with no more symptoms.
After the 5 min. screen comes up:
Order
PT. education
Safe sex
Councel, no alcohol
Councel, no smoking
PAP smear annually
Primary DX
Bacterial vaginosis
Note: if pt pregnant, instead of PO metro, can you apply topical metro? or you give clindamycin?
inputs please.
=======================================
Candida vaginitis
(36 y/o F with 1 week h/o foul smelling vaginal discharge and vulval pruritis).
Location
Office
P/Exam
Abdomen
Pelvic
Extremities
(Pelvic exam will show curdy white discharge and vaginal wall with white patches and erythema).
Rest of the exam WNL.
Order
Vaginal pH,stat
Wet mount prep (saline and KOH),stat
Gram stain of the discharge
PAP smear, routine
GC culture
Chlamydia, culture
CBC with diff.,routine
U/A, routine
(pH > 4.5----> bacterial vaginosis or trichomonas and excludes candida)
(wet mount----> candida, hyphae; motile trichomonas; or clue cells in bacterial vaginosis will be seen).
Results
Fungal hyphae on KOH prep.
Order
Miconazole/Clotrimazole suppositories or vaginal cream x 2 weeks.
Send pt. home.
Schedule appt. after 2 weeks.
Pt. feeling better with no more symptoms.
After the 5 min. screen comes up:
Order
PT. education
Safe sex
Councel, no alcohol
Councel, no smoking
PAP smear annually
Primary DX
Candida vaginitis
Trichomonas vaginitis
(36 y/o F with purulent, malodourous, thin, greenish frothy vaginal discharge with burning, pruritis, dysuria and dyspareunia).
Location
Office
P/Exam
Abdomen
Pelvic
Extremities
Results
Erythema of vulva and vagina; punctate hemorrhages may be seen
Order
Vaginal pH,stat
Wet mount prep (saline and KOH),stat
Gram stain of the discharge
PAP smear, routine
GC cervical culture
Chlamydia, cervical culture
CBC with diff.,routine
U/A, routine
beta-HCG
If high risk sexual behaviour-----> order VDRL, HIV screen and Hepatitis B.
Results
(pH > 4.5----> bacterial vaginosis or trichomonas)
(wet mount----> motile trichomonads seen
Order
Non pregnant---> metronidazole 500mg BID x 7 days or 2gm single dose.
Pregnant----> 1st trimester, Clindamycin cream; 2nd and 3rd trimester, metro.
No alcohol(atleast 48 hrs)--> antabuse effect with metro.
Rx the partner
Send pt. home.
Schedule appt. after 1 week.
Pt. feeling better with no more symptoms.
After the 5 min. screen comes up:
Order
PT. education
Safe sex
Councel, no alcohol
Councel, no smoking
PAP smear annually
No recreational drugs
Age appropriate screening tests and immunizations (e.g,annual mammogram >50 yrs; annual fecal occult blood test and colonoscopy x 10 y > 50 y).
Primary DX
Trichomonas vaginitis
=======================================
Bacterial vaginosis
(36 y/o F with h/o fishy smelling vaginal discharge after unprotected intercourse).
Location
Office
P/Exam
Abdomen
Pelvic
Extremities
Order
Vaginal pH,stat
Wet mount prep (saline and KOH),stat
Gram stain of the discharge
PAP smear, routine
GC culture
Chlamydia, culture
CBC with diff.,routine
U/A, routine
beta-hcg, routine
Results
(pH > 4.5----> bacterial vaginosis or trichomonas)
(wet mount----> clue cells (epithelial cells studded with bacteria on saline wet mount and + whiff-amine test --> fishy odour when 10% KOH is added to the discarge; no inflammatory cells on gram stain).
Order
Metronidazole 500mg BID PO x 7 days
Metronidazole gel x 5days (as effective as oral metro.)
(no need to Rx the partner)
Send pt. home.
Schedule appt. after a week.
Pt. feeling better with no more symptoms.
After the 5 min. screen comes up:
Order
PT. education
Safe sex
Councel, no alcohol
Councel, no smoking
PAP smear annually
Primary DX
Bacterial vaginosis
Note: if pt pregnant, instead of PO metro, can you apply topical metro? or you give clindamycin?
inputs please.
=======================================
Candida vaginitis
(36 y/o F with 1 week h/o foul smelling vaginal discharge and vulval pruritis).
Location
Office
P/Exam
Abdomen
Pelvic
Extremities
(Pelvic exam will show curdy white discharge and vaginal wall with white patches and erythema).
Rest of the exam WNL.
Order
Vaginal pH,stat
Wet mount prep (saline and KOH),stat
Gram stain of the discharge
PAP smear, routine
GC culture
Chlamydia, culture
CBC with diff.,routine
U/A, routine
(pH > 4.5----> bacterial vaginosis or trichomonas and excludes candida)
(wet mount----> candida, hyphae; motile trichomonas; or clue cells in bacterial vaginosis will be seen).
Results
Fungal hyphae on KOH prep.
Order
Miconazole/Clotrimazole suppositories or vaginal cream x 2 weeks.
Send pt. home.
Schedule appt. after 2 weeks.
Pt. feeling better with no more symptoms.
After the 5 min. screen comes up:
Order
PT. education
Safe sex
Councel, no alcohol
Councel, no smoking
PAP smear annually
Primary DX
Candida vaginitis