Others (In Murtagh)
Abnormal Vaginal Discharge
Abnormal vaginal discharge is a change in the color, consistency, volume, or odor of vaginal secretions, often indicating an underlying infectious, inflammatory, or neoplastic condition of the genital tract.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Vulvovaginal candidiasis | White curdy/"cottage cheese" discharge, vulvar itch, erythema; predisposing: DM, antibiotics, OCP, pregnancy [1][3] | 「分泌物係唔係白色、似豆腐渣咁？有冇痕？」 | ~35% |
| Bacterial vaginosis (BV) | Thin grey-white homogeneous discharge, fishy odour (esp after sex); diagnosed by Amsel's criteria (3/4): thin white discharge, clue cells, pH > 4.5, whiff test positive [1] | 「有冇腥味？做完嘢之後味道會唔會重啲？」 | ~30% | |
| Physiological discharge | Clear/white, non-offensive, cyclical variation, no itch/pain | 「平時月經前後分泌物有冇多啲？有冇其他唔舒服？」 | ~20% | |
| Serious Not To Miss | Cervicitis → PID (GC / Chlamydia) | Mucopurulent cervical discharge, pelvic pain, fever, cervical motion tenderness; risk of infertility [2][4] | 「有冇肚痛、發燒？做嘢嗰陣有冇痛？」 | ~8% |
| Ectopic pregnancy / threatened miscarriage | Missed period + discharge ± bleeding ± pain | 「月經有冇遲咗？有冇肚痛同出血？」 | ~2% | |
| Cervical carcinoma | Post-coital bleeding, blood-stained discharge, irregular bleeding in older/unscreened patient | 「你有冇做過子宮頸抹片檢查？最近一次幾時？」 | < 1% | |
| Pitfalls | Cervical ectropion | Post-coital bleeding, mucoid discharge; common on OCP/pregnancy | 「你食緊避孕藥？做完嘢之後有冇出血？」 | ~5% |
| Trichomonas vaginalis | Yellow-green frothy discharge, vulvar itch, strawberry cervix on speculum | 「分泌物係唔係黃綠色、有泡嘅？」 | ~2% | |
| Foreign body (retained tampon/condom) | Foul-smelling discharge, often unilateral | 「你有冇用棉條？有冇可能有嘢留咗喺入面？」 | < 1% | |
| Masquerades | Drug-related (antibiotics/steroids) | Candidiasis post-antibiotic course | 「最近有冇食過抗生素或者類固醇？」 | ~10% |
| Diabetes mellitus | Recurrent candidiasis, polyuria, polydipsia | 「你有冇經常口渴、去好多次廁所？有冇糖尿病？」 | ~3% | |
| Trying to Tell Me Something? | Relationship/infidelity concern | Partner unfaithful → fear of STD; domestic violence | 「你同伴侶嘅關係點呀？你擔唔擔心伴侶嗰邊有問題？」 | ~10% |
| Health anxiety / cancer phobia | Excessive worry, normal discharge | 「你最擔心嘅係咩嘢？」 | ~5% | |
| Sexual assault | Acute onset, psychological distress | Sensitive enquiry if cues present | < 1% |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, introduce self, build rapport | 「你好呀！我係陳醫生，今日由我同你傾吓。你可以叫我陳醫生就得㗎啦。請問點稱呼你？」 | Interpersonal marks: warmth, introduction, ask patient's name |
| 0:30–1:30 | Open-ended exploration of chief complaint | 「咁今日嚟有咩嘢想我幫到你呀？」→ 「可唔可以同我講多少少，個分泌物係幾時開始、係咩顏色、有冇味道？」 | Lets patient tell story; captures HPI naturally |
| 1:30–3:00 | Symptom analysis + red flags + sexual/menstrual history | 「我需要問你一啲比較私人嘅問題，係為咗幫你搵出原因，你介唔介意呀？」→ ask discharge character, itch, pain, bleeding, fever, sexual history, LMP, contraception | Permission-seeking scores highly; red flags show clinical safety |
| 3:00–4:00 | ICE: Ideas, Concerns, Expectations | 「你自己覺得可能係咩問題呀？」「你最擔心嘅係咩嘢？」「你今日嚟最希望我可以點樣幫到你？」 | Direct CRF marks; hidden agenda often here — STD fear, pregnancy worry, relationship concern |
| 4:00–5:00 | PMH, drug history, allergy, social history, impact | 「你有冇其他長期病？食緊咩藥？有冇藥物敏感？」「呢個問題有冇影響到你嘅日常生活、工作或者同伴侶嘅關係？」 | Biopsychosocial marks; functional impact |
| 5:00–5:30 | Summarise back to patient | 「我整理吓你講嘅嘢：你大概兩個禮拜前開始發現陰道分泌物多咗，有啲痕，你擔心係唔係性病。我有冇理解錯？」 | Summarising = high interpersonal marks |
| 5:30–6:00 | Signpost next steps, safety net, close | 「我建議幫你做個檢查同攞啲化驗，睇吓係咩原因。如果你之後有發燒、肚痛或者出血，要即刻返嚟睇。」「你仲有冇嘢想問？」 | Safe closure; safety-net line; checking understanding |
Uncovering the hidden agenda: The symptom (discharge) is rarely the whole story. Ask 「其實你今日嚟，最主要係因為咩原因呀？」 — often the real reason is fear of STD, worry about infertility, partner infidelity concern, or pregnancy.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset/Duration | When did it start? Sudden or gradual? | 「幾時開始有㗎？係突然間定慢慢嚟？」 | Acute = infection; chronic = BV, physiological | Acute: candida, STI; Chronic: BV |
| Character | What colour? Consistency? | 「咩顏色？係稀嘅定杰嘅？似唔似豆腐渣？」 | White curdy = candida; thin grey/white fishy = BV; yellow-green frothy = Trichomonas; mucopurulent = cervicitis (GC/CT) [1][2] | See Murtagh table |
| Smell | Any smell? Fishy? | 「有冇味道？有冇腥味？」 | Fishy odour (especially after sex) = BV [1] | BV |
| Itch | Any itching? | 「有冇痕癢？」 | Vulvovaginal itch = candida; also Trichomonas [1] | Candida, Trichomonas |
| Volume | More than usual? | 「分泌物比平時多好多？」 | Differentiates pathological from physiological | Any pathological cause |
| Bleeding | Any abnormal bleeding? Post-coital? | 「有冇唔正常出血？做完嘢之後有冇出血？」 | Post-coital bleeding → cervicitis, cervical ectropion, cervical CA | GC/CT cervicitis, cervical pathology |
| Pain | Lower abdominal/pelvic pain? Dyspareunia? | 「有冇肚痛？做嘢嗰陣有冇痛？」 | Pain + discharge = PID; deep dyspareunia = endometriosis | PID, tubo-ovarian abscess |
| Fever | Any fever? | 「有冇發燒？」 | Fever + discharge + pelvic pain → PID | PID |
| Dysuria | Painful urination? | 「去小便嗰陣有冇痛？」 | Concurrent UTI or urethritis from GC/CT | GC/CT urethritis, UTI |
| LMP | When was your last period? Regular? | 「你上次月經幾時嚟？準唔準？」 | R/o pregnancy; menstrual cycle context | Pregnancy, hormonal causes |
| Sexual Hx - partners | Sexually active? New partner? Number of partners? | 「你有冇性生活？最近有冇新伴侶？」 | STI risk stratification | STIs |
| Sexual Hx - condom | Do you use condoms? | 「有冇用安全套？」 | Unprotected sex → ↑STI risk | STIs |
| Sexual Hx - partner Sx | Does your partner have any symptoms? | 「你伴侶有冇類似症狀？例如有冇分泌物或者痛？」 | Partner Sx → co-infection, contact tracing needed | GC, CT, Trichomonas |
| Contraception | What contraception do you use? | 「你用咩避孕方法？」 | OCP → ↑candida risk; IUD → altered discharge, actinomyces | Candida, PID |
| Previous STI | Any previous STIs or treatment? | 「你之前有冇試過有性病？有冇治療過？」 | Recurrence, incomplete Tx | Recurrent GC/CT |
| PMH | Diabetes? Immunosuppression? | 「你有冇糖尿病？有冇食緊抑制免疫力嘅藥？」 | Diabetes, immunosuppression, pregnancy = predisposing factors for candida [1][3] | Candida |
| Drug Hx | Recent antibiotics? Steroids? | 「最近有冇食過抗生素？」 | Broad-spectrum antibiotics = predisposing factor for candida [1][3] | Candida |
| Allergy | Drug allergies? | 「有冇藥物敏感？」 | Treatment planning | — |
| Pregnancy | Could you be pregnant? | 「你有冇可能懷孕？」 | Pregnancy changes Mx; physiological ↑discharge; some Tx C/I | Physiological, alters drug choice |
| Functional impact | How does this affect daily life/work/relationship? | 「呢個問題有冇影響到你返工、瞓覺或者同另一半嘅關係？」 | Biopsychosocial CRF marks | Psychological/social problems |
| Health-seeking | Why come today specifically? | 「點解揀今日嚟睇呀？」 | Hidden agenda: partner disclosure, fear of cancer, fertility worry | Psychosocial |
Case Report Form Answer Builder
- Chief complaint: Abnormal vaginal discharge × [duration]
- HPI must include: onset, duration, colour, consistency, odour, amount, associated symptoms (itch, pain, bleeding, dysuria, fever, dyspareunia), relationship to menses, aggravating/relieving factors
- Must document: LMP, sexual history (partners, condom use, partner symptoms), contraception, recent antibiotic use, DM status
- Examples: "Worried the discharge may be an STD," "Partner recently diagnosed with chlamydia," "Discharge affecting sexual relationship," "Wants treatment for persistent itch"
- Phrase it as the patient's reason, not the doctor's → e.g., "Patient is concerned about possible sexually transmitted infection after unprotected sexual contact with a new partner"
| Likely Content | Exact Wording Example | |
|---|---|---|
| Ideas | "I think I might have caught something from my partner" | Patient thinks the discharge may be due to a sexually transmitted infection |
| Concerns | "I'm worried it could be cancer / affect my fertility" | Patient is worried the infection may affect her future fertility |
| Expectations | "I want testing and treatment" / "I want reassurance" | Patient hopes to have swab tests done and receive appropriate treatment today |
- In a young sexually active woman with white curdy discharge + vulvar itch → Vulvovaginal candidiasis
- In a woman with thin grey discharge + fishy smell → Bacterial vaginosis
- In a woman with mucopurulent discharge + new sexual partner → Cervicitis (GC/CT)
- Choose based on stem clues. Minimum evidence: discharge character + key associated symptom + relevant risk factor.
| DDx | One Key Discriminator |
|---|---|
| Bacterial vaginosis | Fishy odour, thin grey homogeneous discharge, pH > 4.5, clue cells |
| Trichomonas vaginalis | Yellow-green frothy discharge, vulvar itch, strawberry cervix |
| Chlamydia/GC cervicitis | Mucopurulent endocervical discharge, post-coital bleeding, pelvic pain; STI risk factors |
(Adjust order based on case stem — if candida is most likely, list BV, Trichomonas, GC/CT as DDx)
| Domain | Problem Example |
|---|---|
| Biological | Vulvovaginal candidiasis causing pruritus and discharge; or PID risking tubal damage and infertility |
| Psychological | Anxiety about possible STD; embarrassment; fear of infertility or cancer; low self-esteem |
| Social | Impact on sexual relationship with partner; concern about partner infidelity; need for contact tracing; work absenteeism due to discomfort |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit It | Why It Supports This Diagnosis |
|---|---|---|---|
| Vulvovaginal candidiasis | Vulvar erythema with white curdy ("cottage cheese") discharge on speculum | Speculum examination of vaginal walls and fornices; inspect vulva | Pathognomonic appearance of candidal vaginitis |
| Bacterial vaginosis | Thin grey-white homogeneous discharge coating vaginal walls; positive whiff test | Speculum + apply 10% KOH to discharge on slide → fishy odour | Amsel's criteria finding [1] |
| Trichomonas vaginalis | "Strawberry cervix" (punctate haemorrhages on cervix) + frothy yellow-green discharge | Speculum examination of cervix | Specific but not always present; frothy discharge is characteristic |
| GC/CT cervicitis | Mucopurulent endocervical discharge; friable cervical mucosa (easily induced endocervical bleeding) [2][4] | Speculum examination; gently swab cervix → bleeds easily | Indicates cervical inflammation from intracellular pathogens |
| PID | Cervical motion tenderness (cervical excitation sign) | Bimanual examination: gently move cervix side to side → pain | Indicates pelvic peritoneal inflammation from ascending infection |
| Cervical carcinoma | Visible cervical lesion (ulcer, mass, irregular surface) | Speculum examination | Visible lesion in unscreened patient with contact bleeding warrants urgent biopsy |
Common Exam Traps
- Forgetting that BV and candidiasis are NOT STDs — do not label them as sexually transmitted infections [5].
- Not asking about pregnancy — always ask LMP; some treatments (metronidazole in 1st trimester, doxycycline) are contraindicated or need caution.
- Not asking sexual history — you WILL lose marks. Use the permission-seeking phrase first.
- Confusing discharge types: White curdy = candida ≠ thin grey fishy = BV ≠ frothy yellow-green = Trichomonas ≠ mucopurulent = GC/CT.
- Missing PID — any woman with discharge + lower abdominal pain + fever → think PID and ask about cervical motion tenderness.
- Not exploring ICE — the hidden agenda (partner concern, fertility worry) is often the main reason for consultation.
- Forgetting predisposing factors for candida — pregnancy, diabetes, immunosuppression, OCP, broad-spectrum antibiotics [1][3].
Must-Not-Miss Red Flags → Urgent Referral:
- Fever + pelvic pain + discharge → PID → same-day Tx to prevent tubal damage
- Post-menopausal bleeding with discharge → r/o endometrial/cervical CA → urgent gynae referral
- Positive pregnancy test + abnormal discharge + pain → r/o ectopic, threatened miscarriage
- Suspected sexual assault → safeguarding pathway
Safety-Net Closing Line: 「如果你之後有發燒、肚痛加重、或者出血，要即刻返嚟急症室睇。我哋會安排化驗結果出咗之後再覆診。」
High Yield Summary
What to ASK: Discharge character (colour, consistency, odour), itch, pain, bleeding, fever, LMP, sexual history (partners/condom/partner Sx), contraception, recent antibiotics, DM, ICE, functional impact.
What to WRITE on CRF: Chief complaint with discharge descriptors + duration; ONE RFC (often STD worry or partner concern); ICE verbatim; most likely Dx with supporting evidence (discharge type + risk factor); 3 DDx with discriminators; biopsychosocial problems; one physical sign (speculum finding or cervical motion tenderness).
What NOT to MISS: PID (pain + fever + cervical motion tenderness), cervical CA (post-coital bleeding in unscreened), pregnancy, and the fact that BV and candidiasis are NOT STDs [5].
Active Recall - Family Medicine Clinical Test
[1] GC 119. Vaginal discharge obstetric and gynaecological infections.pdf (slides on Candida predisposing factors, BV Amsel criteria, Gonorrhoea clinical features) [2] MBBS Final MB (Medicine) (Felix PY Lai).pdf (Neisseria gonorrhoeae and Chlamydia trachomatis sections) [3] Block C - Vaginal discharge_ obstetric and gynaecological infections.pdf (Candida predisposing factors and diagnosis) [4] MBBS Final MB (Medicine) (Felix PY Lai).pdf (Chlamydia cervicitis, PID, physical examination findings) [5] Ryan Ho Urogenital.pdf (STD approach table noting BV and candidiasis are NOT STDs)
Abdominal Swelling / Distension
Abdominal swelling or distension is an increase in abdominal girth caused by conditions such as ascites, organomegaly, bowel obstruction, intra-abdominal masses, or excessive gas accumulation.
Acute Confusion / Delirium
Acute, fluctuating disturbance in attention, awareness, and cognition, typically caused by an underlying medical condition, substance use, or withdrawal.