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Avoid wearing panty liners
6%
10/167
Avoid alcohol consumption
41%
69/167
Schedule testing for HIV
10%
17/167
Perform routine douching
9%
15/167
Schedule her partner for treatment
33%
55/167
Select Answer to see Preferred Response
This woman presents for foul-smelling vaginal discharge with presence of clue cells on microscopy and should be treated for bacterial vaginosis with metronidazole. Due to the risk of a disulfiram-like reaction with oral metronidazole, she should be instructed to avoid alcohol consumption during treatment. Bacterial vaginosis classically presents with watery gray/white discharge that has a fishy odor, and microscopy of the discharge can aid diagnosis if clue cells are seen. The standard treatment is metronidazole, either oral or vaginal gel. Disulfiram is a medication designed to produce discomfort in alcoholics if alcohol is consumed, and if taken with alcohol, oral metronidazole can cause a disulfiram-like reaction. A disulfiram-like reaction may present with nausea and vomiting, headache, palpitations, and respiratory depression. Figure A shows thin white discharge on pelvic exam. Figure B shows clue cells (bacteria covering epithelial cells) on microscopy. Incorrect Answers: Answer 1: Avoiding panty liners would be an appropriate recommendation for a patient with candida, as panty liners can make infection worse. Although this patient’s diabetes does put her at risk for candidiasis, her symptoms and her exam are more consistent with bacterial vaginosis, which is not linked to panty liners. Answer 3: Scheduling testing for HIV would be recommended if the patient presented with another sexually transmitted disease such as chlamydia or gonorrhea, but bacterial vaginosis is not sexually transmitted. Routine testing for HIV should be performed annually for those with risk factors, and this patient just tested negative six months ago. Answer 4: Performing routine douching is not recommended for any patient. Douching can increase the risk of both candidiasis and bacterial vaginosis, and if infection is already present, douching can lead to pelvic inflammatory disease. Answer 5: Scheduling the partner for treatment is not required. Bacterial vaginosis is not a sexually transmitted disease, and partner treatment has not been shown to improve patient outcomes. Bullet Summary: Bacterial vaginosis should be treated with metronidazole, and patients prescribed oral medication should avoid alcohol so as not to have a disulfiram-like reaction.
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