Personal Details:
Name: Mr. Ben Taylor
Age: 20
Medical Record:
Past medical history: No significant past medical history.
Regular medication: None
Allergies: None known
Notes:
The patient saw your practice specialist nurse 3 days ago as he had a sensation of stinging on passing urine. No visible blood in urine, no discharge, no testicular pain.
He also reports a ‘one-night stand’ (one episode of sexual intercourse with a female partner) 2 weeks ago.
He was apyrexial, and the abdomen and external genitalia exam was normal.
Urine dip: +leucocyte, +ve nitrate, otherwise negative
Urine sample was sent for C&S and also for chlamydia testing. No other tests were done.
The nurse gave him a 7-day script for trimethoprim pending results based upon his clinical presentation.
C&S results: <100.000 (CFU)/mL (negative)
Chlamydia +ve
Opening Sentence: “You called me in, doctor? Is everything okay with my test results?”
Open History (to give freely): Patient appears calm initially, as he had thought he had a urine infection when he had the test. The antibiotics the nurse gave him have not made any difference to his symptoms.
When informed of the positive Chlamydia result, he becomes visibly shocked and embarrassed.
Cues to give:
“Does this mean I have to tell her?” (If picked up, the patient will express concern about partner notification and potential conflict).
“I thought I had been careful” (if picked up, express that you used a condom, but you realised it was split)
ICE:
Ideas: Believes Chlamydia is a serious disease. Wonders if he will have long-term health problems. Thinks he might have to tell everyone he knows.
Concerns: Worried about his health and fertility. Concerned about telling his recent partner and the potential awkwardness or anger. Anxious about future sexual relationships. Fear judgment.
Expectation: Wants to be cured quickly. Hopes for a simple solution and to avoid any difficult conversations.
How to Act: Initially calm, then shocked, embarrassed, and anxious. Appears naive about STIs.
More History (only if asked):
· Exposure was 2 weeks ago following unprotected sexual intercourse. His last previous partner was 4 months ago.
· No history of injecting drug use or blood transfusions.
· He denies any symptoms of urethral discharge or testicular pain.
· Sexual History: Heterosexual. No history of previous STIs. Denies anal or oral sex. Had two sexual partners, one four weeks ago and the last one was 2 weeks ago. No other sexual partner in the last 6 months.
· Red flags: No signs of disseminated infection (e.g., joint pain, rash). No fever.
· Social History:
Occupation: University student.
Smoking: Non-smoker.
Alcohol: Social drinker.
Home situation: Lives in student accommodation.
Questions to ask: “How do I get rid of it?” “Do I have to tell the person I had sex with?” “Will this affect my ability to have kids?”
Explain results and manage ICE:
· Thank you for coming in. I’ve got your test results back, and they show that you have Chlamydia. I know this might come as a shock, especially since you only had very mild symptoms, but Chlamydia is a very common sexually transmitted infection, and often people don’t have any symptoms at all.
· The good news is that Chlamydia is easily treatable with antibiotics, and we can get you sorted out quickly. It’s very understandable to feel embarrassed or worried, but I want to reassure you that this is a very common issue. Your main concerns are likely about treatment, telling your partner, and potential long-term effects, and we’ll address all of those.
Next Steps:
· The treatment for Chlamydia is a simple course of antibiotics. I can prescribe you a week's course of Doxycycline 100mg twice daily (if Doxycycline is contraindicated, you can give a single dose of Azithromycin). It’s crucial that you take the medication exactly as prescribed and avoid any sexual activity for 7 days after treatment to prevent re-infection and transmission.
· The most important next step is also partner notification. Anyone you’ve had sexual contact with in the last four weeks (if male symptomatic needs to notify partner in the last 4 weeks, if asymptomatic needs to notify partners in the last 6 months, depending upon local guidance) needs to be informed and tested, even if they don’t have symptoms. This is vital to stop the spread of the infection and prevent potential long-term complications for them.
· We have a confidential service that can help you with this, or you can inform them yourself. We also need to discuss testing for other STIs, as having one STI can increase your risk for others. I’d recommend a full STI screen, including HIV and Syphilis, if you haven’t had one recently. I would recommend having these tests done in the sexual health clinic. You can contact them, and they will usually see people within a few days. Is that okay?
· You were worried whether chlamydia could affect fertility. This will only happen if it is left to cause complications without treatment, as it can cause inflammation in the genital system, which can heal with scar tissue. As long as chlamydia is treated properly early treated this is very unlikely to happen.
· We will need to repeat your urine test for chlamydia after three months to make sure this has been completely treated. You can have that in the sexual health clinic or our surgery. However, if the antibiotic I’m going to give you today doesn’t completely cure all of your symptoms, we may need to do a sooner test in about 3 weeks.
Self-help measures:
Moving forward, it’s really important to practice safe sex. Consistent and correct use of condoms is the best way to prevent STIs. We can discuss proper condom use and other methods of prevention. Regular STI screening is also important, especially if you have new partners or multiple partners.
What is scenario testing? This scenario tests the GP trainee’s ability to manage a positive Chlamydia diagnosis in an asymptomatic young male. It assesses their knowledge of Chlamydia treatment, the importance of partner notification, and safe sex practices. It also tests sensitive communication regarding STIs, confidentiality, and the long-term implications of untreated infections.
Important areas in data gathering:
· Confirmation of diagnosis and explanation of its asymptomatic nature.
· Sexual history: number of partners, types of sexual contact (oral, anal, vaginal), condom use, dates of last sexual encounters.
· Symptoms of other STIs.
· ICE (Ideas, Concerns, Expectations), especially regarding partner notification and future fertility.
Highlight the management objectives. Treatment: Prescribe appropriate antibiotics for Chlamydia.
· Partner Notification: Explain the importance of partner notification and offer support for this process (e.g., GUM clinic services).
· Safe Sex Education: Provide clear advice on consistent condom use and safe sex practices.
· STI Screening: Advise on testing for other STIs (HIV, Syphilis, Gonorrhea).
· Reassurance: Reassure the patient about the curability of Chlamydia and the low risk of long-term complications if treated promptly.
· Follow-up: Advise on re-testing after treatment to confirm cure.
· Confidentiality: Reassure the patient about the confidentiality of the consultation.
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