Volume 10, Number 09

SERUM URIC ACID ELEVATION What are the most likely causes? First we should state the normal range which is 180-450 µmol/L for men and 130-340 µmol/L for women. Increased levels of serum uric acid is found in a number of conditions that may be grouped as follows: Drug-induced Increased cellular destruction Lactic acidosis Overproduction Enzyme defects Any one or more of the above conditions may increase the urate pool which in a normal man on a purine-free diet is about 1200 mg. while in women, the pool is about half that size. Patients with gout may have a problem in not being able to excrete enough urate due to a kidney defect, or they may be producing too much urate. Specific causes include: Gout Hematologic Leukemia Lymphoma Hemolytic anemia Megaloblastic anemia Infectious mononucleosis Myeloproliferative syndrome including Polycythemia vera Chronic renal diseases Drugs, including Diuretic Salicylates including A.S.A. Cytotoxin agents Tissue destruction, all types Alcohol Ionizing radiation Lead poisoning Lactic acidosis Psoriasis, acute phase Toxemia of pregnancy Lesch-Nyhan syndrome

ABDOMINAL PAIN Chlamydia can be the cause Chlamydia trachomatis is the most common sexually transmitted organism in the U.S. today. In females, it typically infects those who are young, single, have low socio-economic status and have multiple sexual partners. Although P.I.D. due to gonococcus has been well recognized, chlamydia is being recognized more frequently as a cause of abdominal pain. Findings may include: Normal cervix (33%), or Mucopurulent cervical discharge Cervical ectopy Erosions Erythema Friability Dysuria and/or frequency Vague lower abdominal pain that may involve the back Dyspareunia Endometritis (40%) Uterine bleeding Salpingitis (up to 30% of acute cases). This is usually milder than GC with less pain, no fever, normal WBC. Disease beyond the pelvic organs, e.g. perihepatitis often mimicking gall bladder disease. Also present may be periappendicitis, perisplenitis, perinephritis and diffuse chlamydial peritonitis with ascities. Pleuritic pain may also occur. The diagnosis of this condition involves making a detailed search involving the patient's sexual, menstrual, and gynecologic history. Culture for Chlamydia by an endocervical swab must be done but may be negative a this stage of the disease. Urethral and endometrial specimens may help. Serum IgG antibody titres to Chlamydia trachomatis are often significantly elevated. Other causes, such as GC, ectopic pregnancy, acute surgical abdomen, appendicitis, endometriosis, must be ruled out. Gilley-PA, Postgrad. Med. 80(8) 321-137, 1986

VAGINAL DISCHARGE Some Distinguishing Features Presented below are some diagnostic characteristics of the five most commonly encountered causes of vaginitis. There are a number of predisposing conditions which should be considered. These include increases in the level of estrogen which raises the secretion of mucous. Such increases may occur preceding ovulation, pregnancy, menstruation, oral contraceptive therapy, obesity and emotional stimulation. Diabetes mellitus may be a factor and antibiotic therapy can upset the natural balance. Overuse of douches and sprays some types of occlusive clothing (e.g. panty hose, swim suits, wet suits, body suits), hot tubs, poor hygiene, retained tampons can all have similar effects. Not to be left out, of course, is the possible exposure to an infected sexual partner. FEATURES OF FIVE COMMON TYPES OF VAGINAL DISCHARGE Physiologic Candida Gardnerella Trichomonas Chlamydia Physical Exam Redness Odour Vaginal mucosa Cervix Absent Absent Pink Pink Moderate Yeasty Dry Pink Variable Fishy Pink Pink Mod.-severe Foul Red, tender Petechiae Absent Absent slightly red Friable Nature of Discharge Colour Consistency Volume Adherence pH Clear-White Flocculent Small Absent < 4 White Curd-like Variable Strong < 4 Gray-White Thin, frothy Abundant Moderate > 5 Green-yellow Frothy Variable Absent > 5 Gray-yellow Mucopurulent Moderate Absent < 4 Comments A noninfectious discharge Pruritis, Dysuria Dyspareunia Cause in 40% of cases. Hard to transmit sexually. 30% asymptomatic Foul odour is most common complaint. Dyspareunia may account for 50% of cases. Sexual transmission occurs. Irritation and discharge are chief complaints. 20-30% are asymptomatic. Prevalence is 20-75% in OPD clinics. Mild symptoms Dysuria Lower abd. discomfort may cause half of all cases of PID Suggested Laboratory Procedures None Office exam of KOH treated slide, heated. Scraping from wall of vagina for C&S. Specimen from Posterior fornix for C&S. Office exam of specimen from post. fornix by hanging drop. Special media if culture warranted Tissue taken by scraping the os with a spatula is best specimen, or a swab from endocervix. Place in special media

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