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Holly Sinations is a 23 year old lady who has presented to clinic with abnormal vaginal discharge. This is having a profound effect upon her life and she is very concerned about the problem/ Please take a history from Holly and perform the appropriate examination. You will then be asked to and present a summary of your findings along with a differential diagnosis, before discussing the case with the examiner.

You are Holly Sinations, a 23 year old lady who has come to the GP today because you have noticed a smelly discharge down below. You have also had some tummy pain and painful urination.

HPC: Over the past week you have noticed that you are producing more vaginal discharge. It is now yellow in colour and foul-smelling. It’s really embarrassing and you haven’t wanted to have sex with your partner because of it.

You have also noticed that it stings when you go for a wee. You don’t think that you’re going more than normal but when you do it can be quite painful. You don’t wake up in the night needing to urinate and you haven’t noticed any change in the smell or appearance of your urine.

You have also had some abdominal pain for about the last week. It is low down in your abdomen, going into your pelvis. It came on gradually and you would describe it more as discomfort than pain. It does not spread anywhere else; nothing seems to make it better or worse. You would rate it 2/10.

If asked about fever, you have noticed that maybe you do feel a bit hotter than usual.

PGH: You have never been pregnant. Your last period was three weeks ago. Your periods are usually regular, bleeding 5/28 and they are not particularly heavy or painful. You currently take the combined oral contraceptive pill and have good compliance. You are too young to have had any smears. You have had thrush in the past but this cleared up with some cream that you bought over the counter. You have never had any bleeding after sex or in between your periods.

PMH: None

FH: None relevant

DH: None except for COCP. No drug allergies

SH: You smoke 10 cigarettes a day and have done since you were 13 years old. You drink quite regularly – you go out every Friday night and will have about 10-12 shots of vodka. During the week you might get through a bottle of wine.

You live with your fiancé, Tom. You work in a shoe shop and Tom is a restaurant manager. Last week, you came back from a “girl’s holiday” in Zante with two of your friends. You were away for a week and had a great time sipping cocktails by the pool and going out every night. On the last night, you had unprotected vaginal sex with one of the travel reps. You didn’t think to use a condom as you were quite drunk and are on the pill anyway. You’re really worried that you might have picked something up from him and don’t know how to tell Tom. You’re worried that Tom might leave you if he finds out. You’ve not had sex with Tom since you’ve come back from the holiday and he has started to notice that something is up. You’ve told him that your thrush has come back but you’re not sure he believes you. You are a bit worried for your safety should you tell Tom the truth. He has never hit you before but he can have quite a temper.

ICE: You think you have picked something up from the travel rep in Zante. You’re embarrassed about the smell and are very worried about having to tell your fiancé. You would like to know what is causing the symptoms and get treatment as soon as possible.

Observe the patient take a full history from this patient. Particularly notice how they deal with the sensitive nature of this consultation. Ask the student to present their findings and present a differential diagnosis, which should include chlamydia/gonorrhoea (NB: gonorrhoea presents with pain in 5% cases, whereas it is much more common in chlamydia infections, making this case more likely to be chlamydia).

Points for discussion: • What might you expect to find on examination of this patient? • What investigations would you carry out? • What are the causative organisms of gonorrhoea and chlamydia? • How do we treat these infections? • If this patient had had unprotected sex with her fiancé since returning from holiday, what are the ethical implications of this and how would you proceed?