Did you know that saying “The Twitter” immediately ages you by 9 years? You know that I was only kidding, right…
Here are the highlights of ambulatory medicine from the last few weeks. Follow @ihaterashes to get these in real time.
While you are following new people on twitter, check out @medicalaxioms. This guy is smart, funny,and usually spot on. Some highlights:
A few things came across my screen about overdiagnosis of breast cancer from BMJ and Annals of IM Just a reminder that raising awareness isn’t enough. A ribbon doesn’t provide any information- that’s our job.
I’m starting to tweet Grand Rounds when I can. #uabmgr. Here’s what I learned in the great talk on The Gut Microbiome given by Martin Rodriguez and Casey Morrow
And finally, I feel the need to share a few articles making the rounds some of the frustration in clinical medicine these days: burnout in Washington Post, competing agendas in NYT (here on Danielle Ofri’s site) and irritation with EMRs in The Atlantic. I have mixed feelings about these things, I love my job and want all of you to become primary care physicians. But burnout is real, as are the administrative challenges of practice. We need to be able to talk about it, and I am relying on all of you to help make it better!
We have been doing wet preps a plenty in resident clinic lately, and I find myself reviewing the same info. That’s sounds like a good reason for a blog post! I’ve organized by diagnosis below, with history, PE, and wet prep clinical pearls.
Bacterial Vaginosis (40-45% of vagnitis)
- HX: profuse discharge, thin, watery. Worse after menses or after intercourse. May be foul-smelling. Usually not painful, pruritic.
- PE: Cup of milk
- Wet Prep: Clue cells. Which is one of those things that is easy to say, but hard to describe. Here’s a picture of normal squamous epithelial cells, followed by clue cells.
Cell borders are smooth, cytoplasm is clear, except for the nucleus.
Cells look “dirty”- cytoplasm is not so clear and the borders are irregular. In reality, the cytoplasm is the same, but bacteria are all around the outside of the cell.
- HX: Thick, white, clumpy, “cottage cheese” discharge, but may be thin and watery. Pruritus, irritation, vaginal soreness
- PE: White adherent discharge. Really don’t need the wet prep to diagnose this.
- Wet Prep: This is where the KOH prep is helpful. KOH breaks down the normal squamous cell walls, so hyphae are left.
- HX: Kind of a mix between the above two. Lots of discharge, foul-smelling, thin (like BV), but pain, pruritus, dysuria (like Candida).
- PE: Strawberry cervix is the board question, but it is rare. More often you see the discharge (it’s thin and yellowish), and the cervical mucosa is red, friable.
- Wet Prep: Trichomonads. Best way to see these is to look at the edges of the sample, and just leave the slide in one place for a while. Trich cells are more round/oval and smaller than the irregular shaped squamous cells. If you are patient, you can often see something moving – might just be the flagella moving, or you might notice the whole cell slowly moving against the flow of the rest of the liquid on the slide.
Cervicitis (GC, Chlamydia)
- HX: discharge is similar to Trichomonas, thin and watery but with associated symptoms of pain/pruritus/dysuria. If systemic sx: nausea, fever, abdominal pain- think PID.
- PE: friable, irritated cervix. Cervical motion tenderness or uterine tenderness on bimanual exam.
- Wet Prep: Normal looking squamous cells, may see lots of white cells (smaller, less clear cytoplasm) in the background.
If you are more of a table person, here’s most of the info above in handy chart form.
||Profuse Discharge, not painful/pruritic
||Women live with this for months before presenting. Worse after menses, intercourse
||Thick, white adherent discharge
||Normal cells, but use KOH to identify Hyphae
||If you see this, can skip the wet prep
||Combo of above- thin watery discharge, also painful/pruritic
||Normal, but with white cells/trichomonads
||Foul smelling discharge (even without the KOH)
||Similar to Trich, friable and painful cervix
||Lots of white cells
||May be GC, Chlamydia, Trich, HSV, others. (always test for other STIs)
Did you know that we have a dropbox for pocket cards? This is so that you can keep them all in your pocket (on your phone). I’ll put the chart below there. If you want a link to the dropbox, send me an email or comment below and I’ll hook you up. Another benefit to reading I Hate Rashes!