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Old 06-27-2011
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ObGyn gonorrhea case (correct me if iam wrong )

A 21-year-old female presents to her primary care provider with a 1-week history of vaginal pruritus. During this period, she has noticed an increase in vaginal discharge and describes it as having a yellow-green color to it. She is current sexually active with one partner and uses a combination oral contraceptive pill (OCP). She has had three previous sexual partners and denies any previous sexually transmitted diseases (STDs). Her previous medical history is unremarkable, and she denies any other symptoms. Physical examination reveals a mucopurulent cervical discharge that appears yellow-green when compared against a sheet of white paper. A Gram stain of vaginal material demonstrates Gram-negative extracellular diplococci. What is the most appropriate next step in management of this patient?

Answer Choices
A. Culture on Thayer-Martin medium
B. Empirical ceftriaxone and doxycycline therapy for her alone
C. Empirical ceftriaxone and doxycycline therapy for her and her sexual partner
D. Empirical ceftriaxone therapy for her alone
E. Empirical ceftriaxone therapy for her and her sexual partner
F. Venereal Disease Research Laboratory (VDRL) titers

Option A (Culture on Thayer-Martin medium) is correct. This patient may have gonorrhea, but demonstrating extracellular gram-negative diplococci can be a part of the normal vaginal flora. Neisseria gonorrhea exists intracellularly. It is important to note that for cases of sexual abuse or assault, the only legally defensible demonstration of gonorrhea is culture.

Option B (Empirical ceftriaxone and doxycycline therapy for her alone) is incorrect. This is the correct pharmacotherapy for her, but her partner should be treated as well.

Option C (Empirical ceftriaxone and doxycycline therapy for her and her sexual partner) is incorrect. Once there is a diagnosis, this is the most appropriate next step in the management of this patient. Of course, an examination and investigation of her partner is desired, but in some circumstances treatment is possible without physician contact.

Option D (Empirical ceftriaxone therapy for her alone) is incorrect. This is the correct drug for Neisseria gonorrhea, but not the correct regimen for two reasons. First, once gonorrhea is diagnosed, chlamydia should be empirically treated, because both conditions frequently coexist, and it is much more difficult to detect chlamydia. Second, her partner should be treated or else she risks reinfection.

Option E (Empirical ceftriaxone therapy for her and her sexual partner) is incorrect. Her partner does require treatment, a principle called “epidemiologic treatment,” but a diagnosis has not been made yet.

Option F (Venereal Disease Research Laboratory [VDRL] titers) is incorrect. Venereal Disease Research Laboratory (VDRL) is a nonspecific test for investigation of syphilis. This patient does not have the painless ulcer (chancre) associated with syphilis, nor does she have any other signs or symptoms consistent with syphilis.


correct me if iam wrong once we dx Gram-negative extracellular diplococci gonorrhea, we rx ption C (Empirical ceftriaxone and doxycycline therapy for her and her sexual partner) we dont do thayer martin culture 1st
am i right
MTB say the same
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  #2  
Old 06-27-2011
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I think is C because you cannot wait until the culture grows. You should start antibiotics while you wait for the results. However, you take the sample for the culture first and then you give the abx. I am not sure if the question is orientated in that way.
Even though you have a Thayer Martin culture negative, you must treat for Chlamydia, therefore waiting for the results before start therapy is non practical from my point of view.

Conclusion: BAD QUESTION
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Old 06-27-2011
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I think the key word is "THE NEXT STEP".. Ya.. You should start the empirical treatment, but before that you should send it for culture on Thayer Martin.. I think after sending for culture you can start empirical treatment with ceftriaxone and doxy
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