Sexually transmitted infections: Clinical

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Sexually transmitted infections: Clinical

USMLE® Step 2 questions

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USMLE® Step 2 style questions USMLE

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A 22-year-old nulligravida woman presents to the walk-in clinic with abnormal vaginal odor. The vaginal odor started two weeks ago and has not improved. She has also noticed vaginal discharge, but denies vaginal bleeding, nausea, vomiting, fever, chills, and abdominal pain. She explains her menstrual period comes every 28 days and the flow is regular. The patient notes she is sexually active with two men and has not been using condoms regularly. Examination shows that her temperature is 37℃ (98.6℉), blood pressure is 125/85 mm Hg, pulse is 85/min, and respirations are 15/min. Pelvic examination reveals thin and frothy vaginal discharge and a normal-appearing cervix. Which of the following is the most appropriate next step in management? 


Sexually transmitted infections or STIs are infections that get transmitted through sexual fluids or skin-to-skin contact during sexual intercourse. Some STIs primarily affect the genital organs- like gonorrhea and chlamydia, while others affect the whole body- like syphilis, HIV, and hepatitis B. Generally, with STIs, all partners with whom there has been sexual contact in the 60 days prior to the diagnosis should be evaluated and treated. On a side note, in this video we’ll be using the term “female” to refer to individuals who have female reproductive sex organs, and the term “male” to refer to those who have male reproductive sex organs.

Okay, let’s start with infections that mainly affect the genital organs like Neisseria gonorrhoeae- which causes gonorrhea, Chlamydia trachomatis which causes chlamydia, and Mycoplasma genitalium - an increasingly recognized pathogen. These infections are usually asymptomatic, but in females, they can cause cervicitis and urethritis. Cervicitis causes changes in vaginal discharge, pruritus in the genital area, intermenstrual vaginal bleeding, or post-coital bleeding. With urethritis, there can be symptoms that suggest a urinary tract infection, like dysuria and frequency. If left untreated, these bacteria can ascend in the reproductive tract and cause pelvic inflammatory disease or PID- which is the inflammation of the uterus, fallopian tubes, the ovaries and of course, the cervix. Acute PID causes lower abdominal pain that worsens during sexual intercourse or sudden movement, post-coital bleeding, and intermenstrual bleeding. Chronic PID causes a low grade fever, weight loss, and abdominal pain. Sometimes, PID can be complicated by a tubo-ovarian abscess which can involve the fallopian tubes, ovaries, or other nearby pelvic organs. Now, in males, these infections can cause urethritis or epididymitis. With urethritis, there’s dysuria and penile discharge, and with epididymitis, there’s unilateral testicular pain and a hydrocele can form around the testicle. In males and females, Chlamydia trachomatis and Neisseria gonorrhoeae can also cause conjunctivitis through direct inoculation with genital secretions. If Chlamydia trachomatis and Neisseria gonorrhoeae come into contact with anal or rectal mucosa, they can cause proctitis, and symptoms include tenesmus, anorectal pain, anorectal bleeding, and constipation. Neisseria gonorrhoeae can also cause pharyngitis, leading to sore throat, pharyngeal exudates, and cervical lymphadenitis.



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