Who you are:
You are FY2 doctor in GP.Who the patient is:
Mr. John Black, 34 years old, came with discharge from his penis.What you should do:
Talk to him, take focused history, give management plan and address his concerns.
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D: Tell me more about it. ODIPARA
P: I started to have this discharge from my penis 2 weeks ago when I was in Greece, after that it became more frequent and painful.
Thick yellow-green colour discharge
Pain while you are passing urine? Yes
Pain in your testicles?
Symptoms of Other STIs:
Ulcers in your private area?
Diarrhoea? Weight loss?
Have you been tested for STIs before?
Have you had this discharge before?
Sexual Hx
D: Sorry, I need to ask you some questions that are quite personal and in depth, but they are related to your condition. If you feel uncomfortable and want me to stop just let me know. Are you sexually active?
P: Yes.
D: Are you in a stable relationship?
P: Yes.
D: Do you practice safe sex?
P: No.
D: By any chance, have you had sex with another partner in the past 6 months?
P: I had sex with a girl while being in Greece.
D: Did you use any method of protection, like condoms?
P: No.
D: Have you had this unusual discharge after this?
P: Yes.
D: Have you had unprotected sex with your partner after this?
P: Yes.
D: By any chance, is your partner experiencing the same symptoms as you?
P: She hasn’t mentioned anything about it.
Examination:
• Observation
• Throat (check for signs of infection)
• Private parts
• Abdominal (if patient is female as they can get PID)
Management
This is a condition which is usually transmitted by having unprotected sex. It is caused by a bug, it is not serious; however, if not treated it could be serious.
Refer to gum clinic
Senior.
Symptomatic:
- Gonorrhoea is usually treated with a short course of antibiotics.
- In most cases, treatment involves having an antibiotic injection (IM Ceftriaxone 1gm one dose at GP)(usually in the buttocks or thigh) followed by 1 antibiotic tablet.
- It’s sometimes possible to have another antibiotic tablet instead of an injection, if you prefer.
- If you have any symptoms of gonorrhoea, these will usually improve within a few days, although it may take up to 2 weeks for any pain in your pelvis to disappear completely.
- Bleeding between periods or heavy periods should improve by the time of your next period.
General advice
- You should avoid having sex until you, and your partner, have been treated and given the all-clear, to prevent re-infection or passing the infection on to anyone else.
- It is advisable to practice safe sex all the time by using condoms. Pills cannot protect you from sexually transmitted infections. Using condoms is the only way to protect yourself from getting these infections.
Sexual partners
- Gonorrhoea is easily passed on through intimate, sexual contact. If you’re diagnosed with it, anyone you’ve recently had sex with may have it too.
- It’s important that your current partner and any other recent sexual partners are tested and treated.
- We may be able to help by notifying any of your previous partners on your behalf anonymously.
- A contact slip can be sent to them explaining that they may have been exposed to a sexually transmitted infection (STI) and suggesting they go for a check-up. The slip will not have your name on it, so your confidentiality is protected.
Patient concerns:
P: Why do you want to tell my wife?
D: May I know why you don’t want to tell her?
P: This could ruin our marriage, it was only one time and I promised myself I wouldn’t do it again.
D: I really appreciate what are you feeling but you told me that you had
unprotected sex with her after having these symptoms and it’s highly likely that you have transmitted the infection to her. So we need to check and treat her because if only you get treated you will get the infection back again from her after.
P: She will leave me if she knows what I did
D: I am really sorry about that, but have you heard about the anonymous
notification program?
P: No.
D: Your partner will receive a letter or an e-email saying that she might have an STI and she needs to get tested without giving her any more details.
P: She doesn’t have any symptoms so why inform her?
D: Sometimes you have the infection without any symptoms, so we need to test her to exclude that because this could have an effect on her health and possibly her fertility.
You:
- You might get infected again if she has the infection.
Your partner
- She might have long term complications like chronic infection, and
infertility.
P: If I don’t give you my permission will you tell her?
D: Well, we would need you to give us her contact details to inform her but as I said we can do it anonymously and your name wouldn’t be mentioned.
Surely you love your wife, and you want to prevent any further harm to her health?
P: Can we have children in the future?
D: Do you have any children right now?
P: No.
D: If both of you are treated early on, then you should be able to have
children like anyone else.
Offer leaflets
Safety netting:
- Testicular pain and swelling
- If your symptoms do not improve (Persisting discharge) after treatment or you think you’ve been infected again, come to us. You may need to repeat treatment or further tests to check for other problems.
- If you develop any fever or redness, heat, swelling around your private parts or groin area, any burning sensation while passing urine, any cloudy or smelly urine please come back to us.
- We usually offer HIV test for those who have sexually transmitted infections. Do you wish to have one?
Follow up:
Attending a follow-up appointment, a week or two after treatment is usually recommended, so another test can be carried out to see if you’re clear of infection.