disease
? Acute, autoinoculable STI
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? Etiologic agent: Gram negative facultative,anaerobic bacillus Haemophilus ducreyi
? `School of fish' or `rail road track' appearance
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in Gram stained smears
? Age group: 20-30 years
? Males affected more commonly
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Clinical features? Incubation period- 3-10 days
? Sites: Frenulum, prepuce, coronal sulcus in
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male and; vulva, vestibule in females? Painful genital ulcers, non-indurated (soft
chancre/soft sore), bleed on touch
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? Edema of prepuce
? Tender inguinal lymphadenopathy (unilateral
in majority), sometimes suppurative
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Investigations
? Microscopy:
? Gram stain ? low sensitivity; may show classic
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appearance
? Culture - < 80% sensitivity
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? Molecular techniques- PCRTreatment
? Recommended regimen
Azithromycin 1 g orally single dose
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orCeftriaxone 250 mg IM in a single dose
or
Ciprofloxacin 500 mg twice daily x 3 days
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orErythromycin base 500 mg orally three times a day x
7 days
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Lymphogranuloma Venereum
(LGV)
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? Also k/a tropical bubo or lymphogranulomainguinale or Durand-Nicolas-Favre disease
? Caused by Chlamydia trachomatis serovars L1,
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L2 & L3
? Incubation period ? 3-12 days
? Males in age group ? 20-30 years
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Pathogenesis? Enters through skin abrasions or mucous
membranes via the lymphatics multiply
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within mononuclear phagocytes in regional
nodes
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? Thrombolymphangitis & perilymphangitisoccur
? Necrosis & the formation of stellate abscesses
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? Fistulae & sinus tract formation; may be f/bhealing with fibrosis
Clinical features
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Primary stage (Genital)
? Superficial ulceration, which looks like herpes,
is temporary and heals without scarring
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? It may not be noticed (GUD with no ulcer)
Clinical features
Inguinal syndrome (Secondary stage)
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? Most common manifestation: bubo - u/l or b/l? Occurs - 2-6 weeks later
? More common in males
? Painful inguinal lymphadenitis with associated
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constitutional symptoms? Enlargement of the femoral & inguinal lymph
nodes separated by the inguinal ligament ?
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"groove sign of Greenblatt"
? Suppuration and sinus formation
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Clinical featuresAnorectal syndrome (Tertiary stage)
? May occur many years later
? Results from fibrosis & lymphatic obstruction
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? Penile and scrotal elephantiasis? Females-elephantiasis of the vulva and clitoris
? Fistulae, chronic ulceration, scarring &
deformity
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Clinical features? Late complications - include rectal strictures,
chronic rectovaginal & urethral fistulae
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? May predispose to malignant change
Investigations
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? Diagnostic method of choice is by nucleic acidamplification tests (NAAT) & confirmation by
PCR assays for LGV-specific DNA
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? Serology:
Complement fixation test ? lack sensitivity /
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specificityMicroimmunofluorescent (MIF) antibody
testing to the L-serovar
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? Frei intradermal test ? historical interest only;based on positive hypersensitivity reaction
Treatment
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? Recommended regimenDoxycycline 100 mg twice daily for 21 days
? Alternative regimen
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Erythromycin base 500 mg four times daily
for 21 days
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Granuloma inguinale / venereum? Chronic, destructive, granulomatous STI
caused by Gram negative organism
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Klebsiella (Calymmatobacterium)
granulomatis
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? Also k/a donovanosis? Incubation period: Not precisely known; about
50 days in human experimental inoculation
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studies
? The organism occurs inside large vacuolated
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histiocytes in the form of "closed safety pin"Clinical Features
? Initial lesion - a papule or subcutaneous nodule
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that ulcerates? Leads to large beefy-red, non-tender
granulomatous ulcers that bleed easily &
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gradually extend
? Secondary infection - result in necrotic, foul-
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smelling, deep ulcers? May be followed by pseudo-elephantiasis
Investigations
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Microscopy:
? Giemsa or Leishman's stain (crush smear
from ulcer) for Donovan bodies
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? Clusters of blue-to-black organisms that
resemble `safety pins' within the vacuoles of
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enlarged macrophagesTreatment
? Recommended regimen
Doxycycline 100 mg orally twice a day for 3
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weeks and until all lesions have completely
healed
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? Alternative regimensOR Azithromycin 1 g orally once per week
OR Ciprofloxacin 750 mg orally twice a day
OR Erythromycin base 500 mg orally 4 times a
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dayOR Trimethoprim-sulfamethoxazole one DS
(160/800 mg) tablet orally twice a day
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Herpes genitalis
? Organism-Herpes simplex virus (HSV-2,
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HSV-1)? Incubation period: 2 days ? 2 weeks
? Primary episode: classically a group of
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vesicular lesions leading to discrete multiplepainful ulcers
? Penile ulceration are most frequent on the
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glans, prepuce and shaft of the penis
? Painful & last for 2?3 weeks if untreated
Clinical features
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? In the female, similar lesions occur on the
external genitalia and mucosa of the vulva,
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vagina & cervix? Pain and dysuria are common
? First episodes are usually more severe than
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recurrencesInvestigations
? Microscopy
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Tzanck smear ? nonspecific, multinucleate
giant cells
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? Culture from vesicle fluid? Detection of viral antigen by
immunofluorescence
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? PCR for HSV DNATreatment
? First episode
Acyclovir 400 mg orally three times a day for 7-10
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days
Or
Acyclovir 200 mg orally 5 times a day
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OrValacyclovir 1 g orally twice a day
Or
Famciclovir 250 mg orally three times a day
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Episodic therapy for recurrenceAcyclovir 400 mg orally three times a day for 5 days
Or
Valcyclovir 1 g orally once a day for 5 days
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OrFamciclovir 1 g orally twice a day for 1 day
Suppressive therapy for recurrence
If > 6 episodes/year
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Acyclovir 400 mg orally twice a dayOr
Valcyclovir 500 mg or 1 g orally once daily
Or
Famciclovir 250 mg orally twice a day
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Urethritis
? Characterized by findings of PMN leucocytes
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in urethral smear or sediment in the first voidurine
- Gonococcal
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- Non-gonococcalGonorrhea
? Gonorrhea - means "flow of seed"
? Albert Neisser identified the organism in 1879
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? Neisseria gonorrheae - Gram negativeencapsulated aerobic diplococcus with pili
? Incubation period- 2-5 days
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Clinical features
? Acute catarrhal inflammation of genital mucosa
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? Men ? Acute inflammation of penile urethra-urethritis
? Burning sensation, dysuria, discharge - yellow,
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thick purulent discharge
? Females ? 50% may be asymptomatic- cervix
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infection? Lower abdominal pain, vaginal discharge or
dyspareunia
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? Throat infection ? due to oral sex on an infected
partner- usually asymptomatic; may cause sore
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throat? May spread in ascending manner, causing
prostatitis, epididymitis, salpingo-oophoritis, PID,
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later infertility? DGI- pain and swelling in or around one or
several joints, fever and chills and skin lesions
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? Ophthalmia neonatorum ? due to infected birth
canal during childbirth
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Investigations? Gram-stained smear ? PMNs with intracellular
G negative diplococci
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? Culture ? Thayer-Martin, Chacko-Nair medium
? Ligase chain reaction ? 97% sensitivity
? Blood culture ? DGI, septicemic
Treatment
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? Recommended regimen
Ceftriaxone 250 mg IM in a single dose OR
Cefixime 400 mg orally in a single dose
PLUS
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Azithromycin 1 g orally in a single dose ORDoxycycline 100 mg twice a day x 7 days
Nongonococcal Urethritis
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Usual causative organisms:? Chlamydia trachomatis [B,D,E,G,H,I,J,K]
? Mycoplasma genitalium
? Ureaplasma urealyticum
? Trichomonas vaginalis
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? May co-exist with gonococcal infectionClinical features
? Dysuria with odorless, mucoid, scanty discharge
? No diplococci but abundant PMNs
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? > 5 pus cells / oil immersion fieldTreatment
Azithromycin 1 g orally in a single dose
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OrDoxycycline 100 mg orally twice a day for 7 days
WITH (for Trichomonas)
Metronidazole 2 g orally in a single dose
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OrTinidazole 2 g orally in a single dose
Vaginitis
Etiology
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? Candida albicans and other species of Candida
? Trichomonas vaginalis
? Bacterial vaginosis
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Candidal vulvovaginitis? Normal flora of skin & vagina ? symptoms d/t
excessive growth of the yeast
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? Balanoposthitis in males
? Risk factors: Pregnancy, DM, HIV infection /
AIDS, repeated courses of broad-spectrum
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antibiotics, corticosteroids? Most cases caused by C. albicans, others by non-
albicans sps e.g., C. glabrata
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Clinical features? Pruritus, frequency & burning micturition
? Dyspareunia
? Thick curdy white discharge
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? Pre-menstrual flare? Examination reveals thick cheesy plaques
Investigations
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? 10% KOH mount: Pseudohyphae with buddingyeasts seen
? Vaginal pH is normal (4-4.5)
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Treatment? Uncomplicated vaginal candidiasis
OTC intravaginal agents
Clotrimazole 1% cream 5 g intravaginally daily for
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7-14 days
Or Miconazole 200 mg vaginal suppository one
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suppository for 3 daysOr Tioconazole 6.5% ointment 5 g intravaginally in
a single application
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Oral agent
Fluconazole 150 mg orally in single dose
Trichomoniasis
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? Caused by Trichomonas vaginalis ? a flagellated
anaerobic protozoan
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? Itching / burning sensation with dyspareunia &dysuria in females
? Frothy, foul-smelling yellowish-green vaginal
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discharge
? `Strawberry cervix' ? petechiae on cervix
? May also cause upto 11-13% cases of NGU in
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males ? usually asymptomatic
Investigations
? Saline wet mount: motile trichomonads in vaginal
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discharge
? Vaginal pH - >4.5
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Treatment? Recommended regimen
Metronidazole 2 g orally in a single dose
Or
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Tinidazole 2 g orally in a single doseBacterial vaginosis
? A disturbance in vaginal microbial ecosystem
? Caused by a mixed flora - Gardnerella
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(Haemophilus) vaginalis, Mycoplasma hominis
and anaerobes
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? Causes grey, homogenous discharge withcharacteristic fishy odour
? Pruritus - not prominent
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Diagnosis
? `Clue cells' - vaginal epithelial cells coated
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with Gardnerella vaginalis (at least 20%)? Whiff test: fishy odour on adding KOH
? Vaginal pH >4.5
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Treatment? Recommended regimen
Metronidazole 500 mg orally twice a day for 7 days
OR
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Metronidazole gel 0.75%, one applicator (5 g)intravaginally, once a day for 7 days
OR
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Clindamycin cream 2%, one applicator (5 g)intravaginally at bedtime for 7 days
Syndromic Management
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? Use of clinical algorithms based on an STI
syndrome, the constellation of patient
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symptoms and clinical signs, to determinetherapy
? Antimicrobial agents are chosen to cover the
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major pathogens responsible for the particular
syndromes in a geographic area
Essential Components
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? Syndromic Diagnosis and Treatment
? Education on Risk reduction
? Condom Promotion
? Partner Notification
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? Counseling? Follow-up
Each component is important for control
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AdvantagesSimple, inexpensive, rapid and implemented
on large scale
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Requires minimum training and used by broad
range of health providers
Disadvantages
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? Over diagnosis and over Rx (multiple
antimicrobials for single infection)
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? Selection of resistant pathogens? Does not address subclinical STI
Urethral Discharge
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Urethral Discharge
Examine for Urethral Discharge: Milking of Urethra
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Discharge seenNo Discharge seen
Rx for Gonorrhea and Chlamydia
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Any other STI
F/u after 7 days
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Use appropriate chartCured
Discharge persists
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T/t regimen followed
regimen not followed
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Refer to higher careRepeat treatment &
Re-evaluate > 7 days
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Genital UlcerNo
No
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Only vesicles present
GUD
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Educate and counselYes
Yes
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Treat for Herpes
Treat for Chancroid and Syphilis
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Treat for Syphilis if VDRL+Treat for herpes if prevalence more than 30%
No
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No
Ulcers healed
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Ulcers improvingRefer
Yes
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Yes
Educate and counsel
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Continue for 7 more daysInguinal Bubo
Enlarged or painful inguinal lymph nodes
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History & examine
No
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Ulcer(s) presentYes
Rx for LGV + Chancroid
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As in genital ulcer chart
14 Days
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Responding to treatmentNo
Refer to higher care centre
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Yes
Presume cured
Vaginal Discharge/ Itch/ Burning
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History
No
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NoVulvul erythema
Any other STI
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Educate
Yes
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YesAppropriate chart
Lower abdominal pain
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Lower abdominal pain chart
No
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YesHigh GC/CT prevalence
Treat for Gonococci/Chlamydia/
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bacterial Vaginosis/Trichomonas
No
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Treat for bacterialYes
Vulvul edema / erythema
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Treat for Candida
Vaginosis
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and TrichomonasNo
Educate
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