Bonnie, a 16 year old ATSI girl who presents with PV discharge and lower abdominal pain. She is sexually active, and reports vaginal and oral sex for the past 1 year, last sexually active 2 weeks ago.   She “sometimes” uses condoms but no other contraception.  She denies any smoking or illicit drug use.  She has no other past medical history.  She has no allergies.  She had incomplete childhood vaccinations.

What investigations do you want to perform? List 8

1. Pregnancy test
2. Urine MCS
3. Self collected vaginal swab PCR (+/- culture for gonorrhoea)
4. First pass urine PCR
5. Hepatitis B serology
6. Hepatitis C serology
7. HIV serology
8. Syphillis serology

GPCC – considering the context of a young female ATSI patient, a self collected swab and urine PCR would be preferable over an endocervical swab.  http://www.sti.guidelines.org.au/populations-and-situations/aboriginal-and-torres-strait-islander#testing-advice

What are your initial medication management recommendations? List 2

1. Azithromycin PO 1g stat [OR Doxycycline 100mg po BD for 7 days]
2.  Ceftriaxone 500mg IMI, stat in 2mL 1% lignocaine

GPCC – From eTG. Be sure to list details – name, route, dose, frequency, duration, in detail.

RACGP – Good answers in this question identified the need for specific investigations and not simply listing all possible investigations or using board terms such as “PCR”, “swabs”, “smear” etc.  The treatment required the correct antibiotics as well as the dose and duration.  When considering the management of this presentation the assessment of the risks to the patient and assessment of her safety given her sexual activity and infection as the appropriate follow up and advice.

Case continued… Her results come back positive for chlamydia and gonorrhoea.  Hepatits B, C, HIV spyhillis serology is negative.  She is not immune to hepatitis B.  Her pregnancy test is negative. Urine MCS normal.

What are your management considerations? List 10

1. Notification to State/Territory public health
2. Contact tracing  of partners back for 6 months
3. Start treatment for patient and sexual partner(s) without waiting for lab results.
4. Advise no sexual contact for 7 days after treatment is administered.
5. No sex with previous partners until they have been tested/treated
6. Discuss and offer contraception to prevent pregnancy
7. Recommend condoms to prevent further STI transmission
8. Offer female ATSI health worker to review her
9. Provide culturally relevant education materiel on STI and prevention  (?Would this get marks?)
10. Vaccinate against hepatitis B as not immune
11. Repeat Hepatitis C and HIV in 3-6 months
12. Organise a follow up ATSI health check appointment

RACGP – Candidates were required to identify issues specific to her cultural background as well as advice relevant to all patients with this clinical presentation.  Many candidates did not correctly identify these issues and so missed marks.

RACGP Feedback

This case required the investigation, treatment and subsequent holistic management of a sexually transmitted infection in a 16 year old indigenous girl.

Good answers in this question identified the need for specific investigations and not simply listing all possible investigations or using board terms such as “PCR”, “swabs”, “smear” etc.  The treatment required the correct antibiotics as well as the dose and duration.  When considering the management of this presentation the assessment of the risks to the patient and assessment of her safety given her sexual activity and infection as the appropriate follow up and advice.

Candidates were required to identify issues specific to her cultural background as well as advice relevant to all patients with this clinical presentation.  Many candidates did not correctly identify these issues and so missed marks.