Duke University
STDS in OP clinicAlison S. Clay, MD1/21/2015Objectives of this Module:Associate key positive findings (in history and physical) for STDS and other disease that can manifest with similar symptomsOrder appropriate testing to guide management and follow-up decisionsProvide anticipatory guidance to a patient with STDS, including the need for followup, and recommendations for additional screening/preventionDemonstrate understanding of mandatory reporting laws for STDs and other conditionsHistory:A 55 year old trucker presents to urgent care with dysuria and penile discharge. He developed these symptoms 2 days ago. He denies any other associated symptoms, no fever, no chills, night sweats.PMH:HypertensionHyperlipidemiaErectile DysfunctionObesityMedicationsSimvastatin 20mgHydrochlorothiazide 25 mgSildenafil PRNSH: Divorced, two children. Long Haul trucker. Smokes 1ppd, 3 beers a night on the weekends only.FH: Father with MI at age 55, deceased. Mother with diabetes and hypertension, aliveIs there any additional history that is missing? What else would you ask? (sexual history)Provide: Interval History to provide to students:Sex with whom: sex with women, sometimes prostitutes at truck stops.Condom use: sometimesAnal receptive sex (important to ask!)-no T: 37.6 RR: 14 HR:85 BP: 134/75Gen: Obese middle aged man in no acute distressEyes: No conjunctival erythema or exudateThroat: No exudate or erythemaChest: No gynecomastia or spider angiomataLungs:, no wheezes and normal I:E ratioCVS: Regular rate and rhythm, no murmurs, rubs or gallopsAbd: obese, unable to palpate any organomegalyExt: no LE edema, 2+ DP pulsesAny additional physical exam findings you are interested in? (what specifically). The provide additional examPenis: Cloudy discharge, no evidence of ulcers (Chancre)Testes: no pain in the epididymis, no testicular swelling, both testes lie in the vertical planeInguinal LAD: NoneProstate (if symptoms of prostatitis are present)Throat—evaluate for exudate in the throatWhat diagnoses do you NOT want to miss? What are their history/physical exam findings?Epididymitis, Disseminated disease, potentially a torsionDiagnosesHistoryPhysicalLab TestsEpididymitisFrequencyDysuriaFeverPain in ONE testicleSwelling of the epididymis50% have scrotal edemaNormal cremasteric reflexNot always from a STD, not always in sexually active UA/Testing for STDSDisseminated Gonococcal DiseaseFever, Malaise, arthralgiasThroat exudateAsymmetric swelling and erythema of the jointsBlood culturesSwab/culture throatAspirate from joint with cultureTorsionH/O trauma, Can be intermittentPain, but usually acute sudden onset of severe painPain in one tesiscleAbnormal cremasteric reflexAbnormal lie of the testesEmergent Ultrasound with DopplerConsult SurgeonWhat are the most likely diagnoses? What are their history/physical exam findings and lab test findings?DiagnosesHistoryPhysicalLab TestsSTDS Gonorrhea or nongonorrheal (chlaymdia)FrequencyDysuriaFeverDischarge from PenisUrethral or cervical swab or DNA PCRUTIFrequencyDysuriaFeverEvaluate for pyelonephritisUA and culture (midstreatm, different than testing for STDS, which is first catch!)If recurrent evaluate for prostatitis in MenProstatitisHigh FeverChillsDysuriaFeverOften have discharge from penisSignificant pain on exam of prostateEdematous prostate on examBEWARE OF SIGNS OF DISSEMINATED BACTERIAL DISEASE if at risk for such (prosthetic valuve)UATesting For STDSSyphilis1-Chancre2-Systemic illness with rash, LAD, malaise, etc3-?VDRL or RPR (check titers and correlate to findings)Confirmatory test for treponemal antibodies with FTA-Abs(conversation about PPV and NPV in populations with low or high prevalence of diseaseHow will you diagnose this patient? What are the advantages/disadvantages to some of the testing?UA would show LE + with WBC>10/hpf (cheap, not sensitive or specific)>5 PMH on urethral swab (painful for men)Positive gram stain on urethral swab (painful for men)Urine for PCR amplification—for gonorrhea and chlamydia This is a test of confirmation, treat if you order the test; Downside—does not culture and therefore cannot determine resistance patternsCulture-may be beneficial because it helps evaluate for bacterial resistanceWill you wait testing or treat now (why/why not?)Treat now, under observed therapy (this is a communicable disease and you have a responsibility not only to the patient but his/her sexual partners; access to medication should not prevent treatment—i.e. not filling a prescription because the patient cannot get to pharmacy or pay for medications)Ceftriaxone 250mg IMAzithromycin 1000g POHow will you treat? How does this treatment change if the patient is older (like this patient) or if they are having anal receptive sex? Cover Gram negative organisms (Trimethoprim/sulfa or levofloxacin)—need to cover for concomitant prostatitis in Men who have sex with men and/or in older menAlso would consider same if patient has recurrent illnessHow would diagnosis and treatment change for a woman?? Need vaginal swab (not urine test)?Assure patient is not pregnantWhen do you test for cure?If treated with second line agentsIf symptoms recur (can be reinfection or another organism such as Mycoplasma genitalium, trichomonas vaginalis, Ureaplasma ureaplasma)Any additional counseling/testing warranted?Consider HIV testing and testing for syphilis with RPR testingScreen for hepatitis A and BAbstain from sexual activity for 7 days?HPV vaccine in younger womanWhat are the mandatory reporting laws for STDS in the state of North Carolina?Positive test results must be reported to the health department.When this occurs, patients will be contacted (so you need a valid contact number) and a sexual history, including names of partners will be asked, so that they can be treated.Other Mandatory Reporting Conditions:Suspected Child Abuse, Elder Abuse in the state of NCDisease for which there are vaccines (Measles, mumps, rubella, etc).Violence with a gun or knifePoisoningsResources:UptodateCDC onlineSanfords Guide to AntimicrobialsAAFP ................
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