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Sexual History

“I'm going to ask you a few questions about your sexual health & practices. I understand that these questions are personal but they are important for your overall health. I ask these questions to all my adult patients. Confidential. Questions?”

  1. Name/age/occupation
  2. PC
  3. HPC: dysuria, discharge, abdo pain, scroatl pain, bleeding
  4. PMH: had this before, last menstrual period
  5. DH: OCP (good at taking it?), abx
  6. Then:

    Partners
    “Are you currently sexually active?” Timing of last intercourse, How many, gender, partners, duration of relationship, RFs (eg. drug use, partners), ppl other than partner
    Practices
    “What kind of sexual contact do you have or have you had?”
    Protection from STDs
    Condoms etc. “Do you & 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 with whom do you use protection?”
    Past history
    STDs, HIV, syphilis
    Pregnancy prevention
    Trying? Condom/OCP.
  7. “What other concerns or questions regarding your sexual health or sexual practices would you like to discuss?”

Risk Factors for sexually transmitted diseases

Investigations

  1. Urine dipstick and MSU for MC+S. Chlamydia can be detected in urine.
  2. Ulcers: swabs for HSV culture, microscopy for syphilis
  3. Urethral smear for gram stain/culture for gonorrhoeae in men endocervix in women, chlamydia swab
  4. High vaginal swab for microscopy/culture for candida, gardnerella, trichomonas
  5. Blood tests: syphilis, hepatitis, HIV serology
  6. Nuclear amplification assays for chlamydia

Common Diseases

Gonnorrhoea

Signs: men
Urethral pus±dysuria, tenesmus, paroctitis±discharge
Signs: women
Often asx. May have vagina discharge, dysuria, proctitis
Complications
Local : Prostatitis, cystitis, salpingitis (pain, fever, infertility), epidimytis, arthritis, Bartholinitis. Systemic : Septicaemia, Reiters. Obstetric : Ophthalmia neonatorum. Long-term : Urethral stricture, infertility
Management
Cefixime. Treat for chlamydia too. No alcohol/intercourse until clear. Treat contacts.

Chlamydia trachomatis

Commoner. Harder to diagnose. Sx/Si similar to ↑.

Complications
Similar to ↑. Rectum/pharynx not affected.Esp Reiters, neonatal conjunctivitis
Management
1 week doxycycline 100mg/12h PO. Single dose of azithromycin 1g PO. No alcohol/intercourse until clear. Treat contacts

Other causes of discharge

Thrush (Candida albicans)
White curds. Vulva/vagina may be red, sore, fissured. Ix: Strings of mycelium/oval spores on microscopy. Management: Imidazole vaginal pessary e.g. clotrimazole. Or one dose of fluconazole 150mg PO
Trichomonas Vaginalis
Vaginitis & bubbly fishy-smelling discharge. Exclude gonorrhoea. Ix: Motile flagellate on microscopy or culture. Management: Metronidazole 400mg/12h PO.
Bacterial vaginosis
Fishy smelling dischage. Itch is rare, no inflammation. Ix: “Clue cells” on microscopy. Management: Metronidazole 400mg/12 PO for 5d, or clindamycin cream.

Other

Hep B
Spread through IV route (Infected blood products, IV drug use, tattooists), sex, vertical
HIV
Sex (esp homosexual), IV drug use, contaminated blood products, organ donations, vertical
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