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Week 10 Assignment: Special Examinations”Breast, Genital, Prostate, and Rectal/Genitalia assessment

 

In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.

To Prepare

  • Review the Episodic note case study for this week’s Assignment.
  • Based on the Episodic note case study:
    • Review this week’s Learning Resources, and consider the insights they provide about the case study. Refer to Chapter 3 of the Sullivan resource to guide you as you complete your Lab Assignment.
    • Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
    • Consider what history would be necessary to collect from the patient in the case study.
    • Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
    • Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

The Lab Assignment

Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.

  • Analyze the subjective portion of the note. List additional information that should be included in the documentation.
  • Analyze the objective portion of the note. List additional information that should be included in the documentation.
  • Is the assessment supported by the subjective and objective information? Why or why not?
  • Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
  • Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

Week 10 Assignment: Special Examinations—Breast, Genital, Prostate, and Rectal/Genitalia assessment

Subjective:

CC: “I have bumps on my bottom that I want to have checked out.”

HPI: AB, a 21-year-old WF college student reports to your clinic with external bumps on her genital area. She states the bumps are painless and feel rough. She states she is sexually active and has had more than one partner during the past year. Her initial sexual contact occurred at age 18. She reports no abnormal vaginal discharge. She is unsure how long the bumps have been there but noticed them about a week ago. Her last Pap smear exam was 3 years ago, and no dysplasia was found; the exam results were normal. She reports one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed.

PMH: Asthma

Medications: Symbicort 160/4.5mcg

Allergies: NKDA

FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD

Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

Objective:

VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs

Heart: RRR, no murmurs

Lungs: CTA, chest wall symmetrical

Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia

Abd: soft, normoactive bowel sounds, neg rebound, neg Murphy’s, neg McBurney

Diagnostics: HSV specimen obtained

Assessment:

Chancre

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

By Day 7 of Week 10

1·• "- J' • I

·-' . Vaginal Discharge and Itching

nfectious causes of vaginal discharge or L ching include Trich?mona~ vc:ginalis, Candida spp., and bactenal vagmos1s (BV), which account for the majority of all vaginal infections in the United States. Sexually trans­ mitted causes of lower genital tract infections include Chlamydia trac homatis, Neisseria 'l(JllOrrhoeae, and Trichomonas vagina/is. – Posnnenopausal patients often have dis­ charge, itching and irritation related to atrophic 1'3ginitis, caused by the deficiency of estrogen in the vaginal tissues. Chemical vaginitis in ado­ le.scents and adults occurs because of the use of scented douches, lubricants, or hygiene sprays

Vulvar itching, burning, and a foul odor often accompany vaginal discharge. Pubic lice, scabies, pinworms, and genital warts (condylomata acuminata) can all cause itch­ ing. Common foreign bodies found in the va­ gina of adult patients are lost or forgotten tampons, which can produce a foul-smelling discharge.

ln childhood and adolescence, vulvar itch­ ing soreness, and vaginal discharge are com­ mon. The lack of estrogen stimulation, neutral pH of the vaginal secretions, lack of protec­ tive thick labia and pubic hair, and daily liv­ ing habits (e.g., wiping, clothing, play activi­ ties, environment, and baths) lead to this rondition. Additionally, the vaginal mucosa is thin and less resistant to infectious organisms. Chemical vaginitis in a child is u sually caused by sensiti vity to bubble bath.

DIAGNOSTIC REASONING: FOCUSED HISTORY

What kind ofvaginitis might this be?

Key Questions ' What is the amount, color, and consistency

of your discharge?

• Do you have itching, swelling, or redness? • Is there an odor?

Characteristics of Discharge Copious amounts of greenish, offensive­ smelling discharge are most consistent with T. vagina/is. Mucopurulent or purulent dis­ charges are associated wi.th gonorrhea and chlamydia. A moderate amount of white, curd­ like discharge is consistent with candida vul­ vovaginitis. BV typically produces a discharge that is thin and white, green, gray, or brown­ ish. Although characteristic symptoms associ­ ated with each type of vaginal discharge can be helpful in arriving at a diagnosis, they are not diagnostic in and of themselves. Micro­ scopic examination of the vaginal discharge is more sensitive than the clinical picture in con­ firming the diagnosis (Fig. 3 7 .1 ).

Itching, Swelling, and Redness Vaginitis causes inflammation of the tissues, resulting in erythema and edema. Because of the inflammatory process, the amount of discharge will produce a concomitant amount of swelling and redness of the vulva and va­ gina. Itching is consistently present with candidiasis. Scratching can lead to excoria­ tions and satellite les ions. BV does n ot in­ volve an inflammatory process and results in discharge with little vulvovaginal erytherna and edema.

Odor A fishy odor caused by the release of amines from organic acids is prominent with BV. It is accentuated by the addition of potassium hy­ droxide (KOH) to the wet mount s lide and is considered a positive "whiff" test. Odor com­ monly accompanies trichomonal infections. Retained tampons or other foreign bodies can also cause a foul odor.

505

Chapter 37 • Vaginal Discharge and Itching

0

FIGURE 37 .1 Microscopic differential diagnosis of vaginal infections. A, Clue cells (epithelial cells with c lumps of ba c teria) are evident in ba c terial vaginosis. B, Budding, branching hyphae characterize candi­ diasis . C, Motile tri c homonads are seen with tric ho moniasis. (From Zitelli BJ , Davis HW: Atlas of pediatric physical diagnosis, ed . 3 , St Louis, 1997, Mos by-Wolfe.)

Is this likely a sexually transmitted infection?

Key Questions • Are you sexually active? Do you have

multiple partners? Do you have a new partner?

• Have you had sex against your will? If a child, you might ask, "Has anyone touched your private parts?"

• What form of protection do you use? How often do you use protection?

• Have you or your partner(s) ever been tested or treated for a sexually transmitted infection (STI)?

• Do you have any rashes, blisters, sores, lumps, or bumps in the genital area?

Sexual History Early-age onset of sexual act1v1ty, multiple partners, and nonuse of barrier contracep­ tives, particularly condoms, increase the risk of vaginal infection. STis are common in patients of childbearing age (12- 50 years) who have acquired a new partner, but the highest prevalence is in sexually active young adults younger than age 24 years. The patient who frequently changes sexual partners or participates in risky sexual practices (e.g., anal intercourse without a condom) is at high risk for STls.

Do not ignore the possibility of an STI in older adults or children. About half of all children with an STI have been found to be sexually abused. T. vagina/is is rare in chil­ dren but can be transmitted to a neonate from an infected mother.

Recent Treatment for a Sexually Transmitted Infection Recent treatment for an STI may indicate treatme nt failure, a coinfection that was not covered by the prescribed drug, or recent exposure.

Lesions Vesicles usually indicate herpes infection. Pa­ tients typically notice them on the external labia and report that they itch or burn. Condy­ lomata lata, condylomata acuminata, and mol­ luscum contagiosum are a ll papular lesions found on the labia, perineum, and anal regions. Molluscum contagiosum, when occurring in the genital area, may extend to the inner thighs. Typically, condylo m ata acuminata (genital warts) are rough, verrucous lesions that are usually located inferiorly from the fossa na­ vicularis to the fourchette and perinea! area. A painless ulcer suggests syphilis and classically appears as a solitary les ion. However, there can be more than one chancre, especially if the patient is immunocompromised.

~

• 6t '"'ginitis tlrat is not related

'11

stions 'tyou ever been told that you have dia-

Cushing syndrome, or human im­ ~eficiency virus (HIV) infection? flave you been ill recently?

' AJC you taking antibiotics, hormones, or ' (fa! contraceptive pills? , Have you received chemotherapy? , ()oeS the itching seem to be worse at

night? , Can you describe some of your recent ~vities? Ifan adolescent: Have you had a menstrual pen'od?.

nocompromised States ory fungal vulvovaginitis may indicate osed diabetes or an imrnunocompro­

fever, and measles can lllSe vaginitis.

ledications or Chemotherapy 11th control pills, corticosteroids, antibiotics, llcbemotherapy are associated with candi­ 11 vulvovaginitis. Oral contraceptives can ierthe vaginal pH, and antibiotics can alter ~ nonnal vaginal flora; both predispose to

Chapter 37 • Vaginal Discharge and Itching

fungal infection. Corticosteroids and chemo­ therapy can produce an immunocompromised state and provide the opportunity for fungal infection.

Night Itching Pinworms are intestinal parasites that inhabit the rectum or colon and emerge to lay eggs in the skinfolds of the anus. Perianal pruritus, especially at night, along with pain or itching of genitals is common (Fig. 3 7 .2).

Activities Riding a bicycle, using pools or hot tubs, or wearing tight-fitting pants or pantyhose can lead to heat and moisture in the genital area, causing mechanical irritation and such infec­ tions as candidiasis or BV.

Premenarche Children who have not yet reached menarche are prone to vulvovaginal infections because of a nonestrogenized vagina and the lack of labial development and hair growth.

Is this condition acute, recurring, or chronic?

Key Questions • How long have you had these symptoms? • Are they getting better or worse? • Have you ever had these symptoms

before?

u

mature worm is shown sur­ (From Zitelli BJ, Davis HW: Atlas of

Chapter 37 • Vagin al Discharge and Itching

• How many episodes have you had in the past year?

• Are the episodes related to any particular activity or time?

Chronology of Symptoms The occurrence of vaginal discharge after having a new sex partner suggests an acute condition, such as an STI. Symptoms associ­ ated with use of condoms or spermicidal jelly suggest sensitivity to the product. Tf the discharge occurs monthly with worsening after menses, suspect a chronic condition, such as vulvovaginitis candidiasis. Recurrent episodes related to bathing activities point to chemical irritation.

Ifthis is acute, could it be related to a previous infection?

Ke y Questions • Have you been tested and treated for

this condition? What medication was pre­ scribed?

• Did you take all of the medication? • What other prescriptions were you taking

at that time? • What over-the-counter medications have

you taken?

Adequate Diagnosis Diagnoses made clinically on the basis of the color or appearance of discharge may be incor­ rect, or a concomitant vaginal infection may have been missed. However, self-diagnosis and treatment are common, especially with the over-the-counter medicines for "yeast infection."

Adequate Treatment Medication regimens that are not single dose present a challenge to treatment completion. Patients may stop u sing vaginal medications when menses begins and resume after it ends. They may also discontinue the medica­ tion early, as soon as symptom relief occurs, or if they have a drug side effect (e.g., the metallic taste of metronidazole). Drug inter­ actions may account for inadequate therapy, or the intake of certain foods or substances,

such as alcoholic beverages, may need to be restricted.

If this is chronic, what should I suspect?

Key Questions • Have any family members or sexual part.

ners reported itching, rashes, sores, lumps or bumps with any vaginal or urinary trac~ infections?

• Do you have a new or untreated partner? • What are your sexual practices (e.g., vagi­

nal , oral, anal sex)? • Have you had recurrent yeast infections in

the past year?

Transmission Caregivers, parents, and siblings can spread infections, such as candidiasis, molluscum contagiosum, herpes, lice, and pinworms, to children through poor hygiene practices. Autoinoculation is also possible, especially for herpes, genital warts, and molluscum contagiosum.

New or Untreated Partner The most common cause of reinfection is in­ tercourse with a new or untreated partner.

Sexual Practices Possible infection reservoirs are oral and anal cavities, which may need to be cultured for herpes or gonorrhea. Additionally, materials used during intercourse may need to be disin­ fected (e.g., diaphragm, sex toys). Less com­ mon modes of transmission include shared intimate clothing.

Recurrent yeast Infections Ifthe patient has had more than three separate episodes of candidal vulvovaginitis in l year, consider diabetes or the immunocompromised state of HIVI AIDS as the underlying cause. Yeast grows best in areas that are dark, moist, warm, and high in glucose, areas where the normal flora has been compromised. Oral contraceptives, hormone replacement therapy, antibiotics (e.g., tetracycline for acne), ste­ roids, diets high in carbohydrates or artificial sweeteners, and clothing that holds moisture

Chapter 37 • Vaginal Discharge and Itching

. the vulva (e.g., pantyhose, tight jeans) ~. factors associated with vulvovaginitis. , (1)1'

" 'rt otlrer possible causes for this ,.itis?

~uestions ltfWhat are your personal hygiene practices?

00 you douche? ffave you changed brands of contraceptive products?

' could you have forgotten to remove your diaphragm or tampon?

IJliene Practices fclllinine hygiene practices can contribute to lgirtitis by causing a local allergic reaction,

vaginal flora, or contamination of the · from the rectum. Perfumes in douches,

, lubricants, and bubble baths are fre­ t offenders in allergic vaginitis.

en a child is out of diapers, toileting is closely assisted, and wiping techniques be poor, leading to contamination of the

with bowel flora.

ing Frequent douching can change the balance of amal vaginal flora by altering the pH and is urecommended. This allows recolonization i the vagina with enteric bacteria, leading to imritus and discharge. Douching can cause 11 allergic reaction. Colored or perfumed toilet paper can irritate the perineum, causing redness and itching. Wiping with tissue after urination or defecation in the direction from fueanus toward the vagina can inoculate the vagina with rectal microbes .

Contraceptive Products Contraceptive products (e.g., spermicidal jellies, suPPositories, foam, and latex condoms) can l'ause an allergic inflammation of the sensitive lllucosa and produce itching, erythema, tender­ lless,and an increase in usual vaginal secretions.

foreign Body

Foul-smelling vaginal discharge can be caused b got _Y a lost tampon or condom or a for-

ten diaphragm. A child who puts a foreign

object into the vagina may have pruritus, burning, or foul, purulent vaginal discharge. Foreign bodies in the vagina are associated with vaginal bleeding or spotting. If the object is left for some time, it can imbed and perfo­ rate the vaginal wall.

Are there any associated symptoms that point to a cause?

Key Question!; • Do you have burning or pain with urina­

tion? Do you have urinary frequency or hesitation or nighttime urination?

• Is intercourse painful? • Do you have abdominal or pelvic pain? • If an infant: Does the infant have an eye

infection? • If an infant: Does the infant have a cough?

Urinary Tract Symptoms Atrophic vaginitis is often accompanied by dysuria, dyspareunia, and vaginal dryness. Estrogen deficiency affects the patient's entire lower genital tract and may produce symptoms that can be confused with a uri­ nary tract infection. Low estrogen levels may exacerbate stress and urge incontinence. Trichomonas and chlamydia may produce a coexisting urethritis that causes frequency and dysuria.

Dyspareunia and Pain Vaginal atrophy, genital warts, or vaginal infec­ tions can cause dyspareunia. A more likely reason for deep vaginal dyspareunia is endome­ triosis, pelvic inflammatory disease (PID), or fibroids. STis such as gonorrhea and chlamydia can cause cervicitis, which, if left untreated, can progress to PID and produce abdominal or pel­ vic pain (see Chapter 3).

Eye Infection Eye infections in a newborn may be associ­ ated with g onorrhea and chlamy dia (see Chapter 30).

Cough Pneumonia in the n ewborn may be an indica­ tion of chlamydia (see Chapter 11 ).

Chapter 37 • Vaginal Discharge and Itc hing

DIAGNOSTIC REASONING: FOCUSED PHYSICAL EXAMINATION

Note Vital Signs The presence of a fever may a lert you to a serious infection. such as PIO. Fever is un­ common with vaginitis.

Perform an Oral Examination Oral thrush may accompany v ul var candidia­ sis, particularly in childre n . Look for w hite patches that bleed when you try to scrape them off.

Perform an External Genitalia Examination Palpate for inguinal lyrnphadenopathy and tenderness, which can be present with vaginal infections. Inspect the vulva and labia, look­ ing for erythema, excoriations, and indura­ tion. The skin is often bright red and swollen with small fissures or excoriations from can­ d idiasis. A lso, thick white curds of discharge are often noted in the labial fo lds. BV often produces a profuse, thin, whitish discharge that will leak o u t of the vagina onto the perineum. Palpate Bartholin and Skene glands and milk the urethra for discharge. Palpable Bartholin glands often coexist with STis. If purulent discharge is seen, consider the diag­ noses of gonorrhea or chlamydia and obtain s pecimens for diagnostic tests.

Condylomata lata, condylomata acumi­ nata, and molluscum contagiosum are all papular lesions found on the labia, perineum, and anal regions. Molluscum contagiosum, when occurring in the genital area, may ex­ tend to the inner thighs. Herpes lesions are usually ulce rative in nature when seen clini­ cally and need to be differentiated from other s imila r lesions (e.g ., syphilitic chancre can be more than one lesion and tender if second­ ari ly infected). Herpetic lesions- painful vesicles on an erythematous base-are fou nd in clusters and can extend from the labia into the vagina. Typically, condylomata acumi­ nata (genital warts) are rough, verrucous les ions that ar e located inferiorly from the fossa navicularis to the fourchette and peri­ neal area.

In an overweight patient, vulvovaginitis candidiasis is frequen tly accompanied by

intertriginous candidiasis (e.g., under th breasts and the abdomina l apron). e

In a young chi ld, it is important to tell he in simple te~s what you ~e ~bout to do. ~ common pos1t1on for exammat1on is the fro leg position. Have the parent sit on a chair an~ then have the patient s it on her parent's lap for the examination. The most common problem (vulvovaginitis) of the younger child requires only the lower third of the vagina to be visual­ ized. A more detailed visual examinati on re­ quires labial separation and labial traction.

Perform an Internal Vaginal Examination Note the condition of the vaginal walls. A plastic speculum makes vaginal wall inspec­ tion easy and helps in the identification of a foreign body for removal. In children, the knee-chest pos ition is useful for inspecting the vagina. If a foreign body is suspected in c hildren, removal is done using sedation. Pale or mottled red splotches of the vaginal mu­ cosa with a sticky, yellow-brown discharge are associated with atrophic vaginitis. In se­ ver e cases of atrophic vaginitis, the pale, thin mucosa may have adhered to the opposing vaginal wall, and the speculum examination often causes an oozing bloo dy discharge.

The appearance of the cervix should be noted. A friable or "strawberry" appearance of cervical petechiae with a frothy, foul- smelling discharge is descriptive of a trichomonas in­ fection. A mucopurulent discharge from the cervical os requires an endocervical sample for gonorrhea and chlamydia testing. This discharge is yellowish-green when collected on a n endocervical swab . The character of the discharge does not con s istently identify com­ mon infectious causes of vaginitis. Treat vag­ ina l infections b efore the P apanicolaou test is obtained because BV and trichomoniasis may cau se inflammatory atypia resu lts .

Obtain a sample for testing. The wet mount is a valuable diagnos tic too l, and a sample of vaginal discharge is b est obtained from the lateral vaginal fornices. Three positi ve char­ acteristics for any one etiology can correctly identify the causative agent (e.g., increased pH; the presence of "clue cells ," which are epithelial cells fu ll of bacteria that obscure the cell border; and a thin gray discharge seen in

Chapter 37 • Vaginal Discharge and Itchingr e Differential Diagnosis). Molecular

~,·~ ~:~r culture may also be indicated (see r.-s1111~ tor)' and Diagnostic Studies). C ultures L~~~- fungal infections, and T. vagina/is are ~ir utinely recommended and are usually r.Jl ~ed for determining resistant organisms. reset'

erlorm a Bimanual Examination p ess the condition of the uterus, fallopian A~ and ovaries by checking for uterine and !Urvi~al motion tenderness (CMT), ovarian ~e, and presence of masses. CMT or pain on ralpation of the uterus and adnexa confirms tlJe spread of vaginitis or cervicitis to the up­ r:r genital tr~ct and res~lts in PID. This war­ rants immediate evaluation and treatment or referral to prevent tubal scarring, ectopic pregnancy, and infertility.

Morm a Vaginal-Rectal Examination 'aginal-rectal examination is a technique in assessing the posterior uterus and condition of the cul-de-sac as well as the rectum. The in­ !fmal examination glove must be changed ~fore rectal insertion to prevent contamina­ tionof the rectum with vaginal discharge or­ ~ms. A rectal examination, u sing the fifth digi~ is used to palpate a foreign body and to rheck pelvic anatomy in the child.

lABORATORY AND DIAGNOSTIC HUDIES Potassium Hydroxide and Wet Mount or Preparation Obtain a discharge sample from the lateral fornices of the vagina using a cotton-tipped c~plicator. There are several acceptable tech­ niques for preparing a diagnoses and wet lllount. One is to prepare two slides with a ~ear of vaginal disch arge. To one slide, add

drop of l 0% KOH an d put a coverslip in Place. To the other s lide, add 1 drop of normal 1~ine and put a coverslip in place. The result Qfthe whiff test is positive when the addition ~ the 10% KOH produces a fishy odor, which .: caused by the release of amines. The whiff ~Vst has a positive predictive value of 76% for .. L rd 00k under the microscope at the KOH

·n: ~or the presence of branching and bud­ yPhae that are c haracteristic of yeast

infection. Examine the saline wet mount mi­ croscopically for motile trichomonads that signal the presence of trichomonas. Clue cells are characteristic of BV (see Fig. 3 7 . 1).

Test for pH Most litmus paper reads the pH range from 3.0 to 9 .0. This is a simple inexpensive test to aid in determining the cause of the vaginal discharge. Normal vaginal secretions have a pH less than 4 .5. A pH greater than 4.5 is consistent with BV, trichomoniasis, or atro­ phic vaginitis.

Fungal Culture or Sabouraud Agar Culture Fungal culture may be needed in the diagnosis of non- Candida albicans (e.g., C. glabrata, C. tropicalis, C. krusei) that are refractory to medication regimens.

Herpes Viral Culture Viral culture is the most specific method of diagnosing herpes. Res ults may take from 1 to 7 days, with maximum sensitivity achieved at 5 to 7 days. The herpes culture will probably not be able to identify the causative agent if the specimen is taken from a lesion that is 5 or more days old. It is important to document positive genital herpes infections in the preg­ nant patient and in skin lesions of the new­ born. Collect cells or fluid from a fresh sore with a cotton swab and place them in the cul­ ture container. You may need to unroof a vesicle to obtain a specimen.

Herpes Virus Antigen Detection Test This test detects antigens on the surface of cells infected with the h e rpes virus. Cells from a fresh sore are scraped off and then smeared onto a microscope s lide. This test may be d one in addition to or in place of a v iraJ c ulture.

Tzanck Smear Characteristic findings of a Tzanck smear are muJtinucleated gia nt cells that are like ly to be found if the specimen is from an intact herpes les ion. Prepare the Tzanck smear by remov­ ing the roof of the vesicle and scraping the skin with a scalpel blade. Make s ure that the base and the margins of the vesicle are scraped. Do not use the vesicular fluid for thi s

Chapter 37 • Vaginal Discharge and Itching

specimen. The cellular material is spread onto a g lass slide, fixed with absolute alcohol for 1 minute, and then stained with Wright s tain. Alternative staining methods are available, and guidelines can be obtained from local laboratories.

Modified Diamond Culture Diamond culture can be used to identify Tric homonas spp., but it is seldom needed to make the diagnosis.

Thayer-Martin Culture Thayer- Martin medium is a bacterial culture that identifies gonococcal infections. A cul­ ture is taken from the endocervical canal of the uterine cervix. First remove excess mucus from a portion of the cervix using a cotton ball held in ring forceps or a large cotton­ tipped procto-swab. Insert a sterile cotton­ tipped applicator (Q-Tip) into the endocervi­ cal canal and allow it to absorb the mucus for I 0 to 30 seconds before inoculating the me­ dium. Inoculate the medium bottle or plate in a zigzag manner while simultaneously rolling the small cotton-tipped applicator. When opening the Thayer-Martin culture bottle, avoid holding the bottle totally upright, which will allow for the loss of the carbon dioxide from the specimen collection bottle.

A meta-analysis of 21 studies and more than 6100 paired samples estimated the accuracy of self-collected samples compared with clinician­ collected samples for diagnosing ch lamydia and gonorrhea. Six studies compared se lf-collected vaginal samples with clinician-collected c ervical samples. When the studies were pooled , sensi ­ tivity was 0 .92 (95% confidence interval [Cl] , 0 .87-0 .95), and specificity was 0.98 (95% Cl, 0.97- 0 .99) . Taking into account that urine samples may be less sensitive than cervical samples, eight c hlamydia studies that compared urine self-collected versus c linician – collected cervical samples had a sensitivity of 87% (9 5% Cl, 81 – 91) and high specificity of 99% (95% Cl , 0.98-1.00).

For gonorrhea in women, three studies com­

num

an

pared self-collected urine samples with clinician­ col lected cervical swabs. The poo led sensitivity was 0. 79 (95% C l , 0. 70-0.88), and spec ificity was 0.99 (95% Cl, 0.99- 1.00). One cross­ sectional study (n = 309) compared self· collected vaginal samples with clinician-collected cervica l samples. The reported sensitivity was 0. 98 (95% C l , 0.88- 1.00), and the specificity was 0.97 (95% Cl , 0.94- 0.99).

The authors concluded that the high se r1 sitiv­ ity and specificity of vaginal self-collected .:,wabs compared with swabs collected by cl .. :1c1ans supports the use of vaginal swab se lf -cc ·; .'•:t1 on for chlamydia and gonorrhea testing i n vv, 1 ien.

Molecular Testing for Infectious Organisms Molecular testing using a sample taken the vagina provides r a pid, sensitive, and s cific results. Molecular testing has large ly re placed the need for culture methods. A ber of products are available. Tests incl ud DNA probes, nucleic acid amplification tes (NAATs), and polyme rase chain reac tio (PCR) assays. Tests are available for C. tra chomatis, N. gonorrhoeae, T vagina/is, Gard nerella vagina/is, Candida spp., and herpe simplex virus. Samples for chlamydia gonorrhea testing can be obtained by the clini cian or by the patient. Urine NAATs can b used to screen for possible STis in both adults and children.

Syphilis Testing Serology tests are used for screening and diag­ nosing syphilis and are recommended if other STis are found or suspected. The screening tests are nontreponemal and include Venereal Disease Research Laboratory, rapid plasma reagin, and enzyme immunoassay tests. Diag­ nostic tests are T pallidum- specific and include FTA-ABS (fluorescent treponemal antibody absorption test) and T pallidum particle agglu­ tination assay. Detection of T. pallidum can also be done using PCR molecular testing.

2_ EVIDENCE-BASED PRACTICE Se(f-collected J/aginal Su•ahs Co111pared 1vith Cli11icia11-Collectetl S1vahs

Reference: Lunny et a l , 2015.

Chapter 37 • Vaginal Discharge and Itching

. 1ysis ·s should be obtained if the patient

p3 l)'SI l . . ,fl ria However, externa pam on un­ . dysu . fr . .

~. may originate om unne on 1n­ pnond vulvar tissue, e liminating the need i'Jllle . . urinalysis. !Jf

~;croscopy and S~in Scraping . . . ;no a skin scrapmg under the rmcroscope is

!(II :> • th diffi . I ct• . f .111 10 assist with e erentla 1agnos1s o ; bies and pubic lice (see Chapter 28).

icotchTape Test l.'se this test when you suspect pinworrns ,£nterobius vermicularis), which occur most '°mmonly in children. Instruct the adult to IPPIY clear adhesive cellophane tape to the .IDld's perianal region early in the morning rben the child awakens. The tape i s then re­ ool'ed, placed in a plastic bag, and brought i1IO the clinic. Place it on a glass slide and l!allli ne it under a microscope for the pres­ m of eggs. Parents may also be able to see !he wom1s by shining a flashlight on the ex­ itmal anus of the child at night. A female ionn is about 10 mm long (see Fig. 3 7 .2).

Acetic Acid Test (Acetowhite) Theaceti c acid test is best used to detect sub­ :linical lesions caused by human papilloma­ •llUs (HPV) when a genita l wart has been ident ified, when there has been sexual con­ iact, or when the Pap test indicates dysplasia. ~e application of 5 % acetic acid (vinegar) to :ne. cervix, labia, or perianal area causes the csion to tum white (acetowhite). Saturate a ~~e pad with vinegar …

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