1. WELLONE PRIMARY MEDICAL AND DENTAL CARE For Medical Provider Staff Click here to move on

2. Conducting this test exposes the operator to potentially infectious material. Standard precautions, including glove use are required for this procedure. Click here to move on Click here to go back

3. Vaginal pH testing and wet mount are indicated based on patient complaints and symptoms; rarely is “asymptomatic” pH or wet mount testing indicated. The absence of trichomonads or pseudohyphae does not rule out infections because several studies have demonstrated the presence of these pathogens by culture or PCR after a negative microscopic examination. Patients with symptoms of bacterial vaginosis generally complain of an increased vaginal discharge with a foul, fishy odor that becomes more pronounced with menstruation or after unprotected intercourse. The patient may also experience some attendant irritation. Examination discloses a normal vulvar area and vagina as well as a copious, homogeneous, white-to-gray discharge, which is easily wiped from the vaginal wall. Click her to go back Click here to move on

4. Obtain discharge from the lateral fornices. Avoid the cervical mucus, which has a higher pH than the vagina. Avoid using lubricating jelly (will interfere with PH and Wet mount results as well as cervical pathology specimen; speculums can be lubricated with water) Compare the color to the chart on the container. Click her to go back Click here to move on

5. True False Click here to select this answer Click here to select this answer Click her to go back

6. Discharge should be obtained from the lateral fornices. Cervical mucus should be avoided since it will interfere with pH testing. Click her to go back Click here to move on

7. Normal vaginal pH is 3.8-4.5 pH >4.5 is consistent with BV, trich and atrophic vaginitis A normal pH is seen with candida Limitations: blood, sperm, and cervical mucus can elevate the pH; acid gels may lower the pH. Click her to go back Click here to move on

8. 4.0-6.0 4.5-5.0 3.8-4.5 Click here to select this answer Click here to select this answer Click here to select this answer Click her to go back

9. 3.8-4.5 Click her to go back Click here to move on

10. Place one smear of discharge on one side of the slide and another smear on the other side of the slide. Avoid placing too much discharge on the slide as a thick specimen interferes with readability of the slide. Click her to go back Click here to move on

11. Add one drop of NaCL to one area of the discharge and one drop of KOH to the other side and mix with end of wooden stick/swab Observe for a fishy odor with the addition of KOH (whiff test) which is an indicator of bacterial vaginosis (positive whiff test)Two Apply a coverslip to each side Click her to go back Click here to move on

12. A negative whiff test; Bacterial Vaginosis A positive whiff test; Candida A positive whiff test; Bacterial Vaginosis Click here to select this answer Click here to select this answer Click here to select this answer Click her to go back

13. A positive whiff test; Bacterial Vaginosis Click her to go back Click here to move on

14. Begin on low power. Scan the entire slide- observing for yeast and Trichomonads on the saline side and clue cells on the KOH side. Click her to go back Click here to move on

15. A diagnosis of Candida vaginitis is suggested clinically by the presence of external dysuria and vulvar pruritis, pain, swelling, and redness. Signs include vulvar edema, fissures, excoriations, or thick curdy vaginal discharge. The vaginal ph is <4.5 Wet mount examination may reveal budding yeast and/or pseudohyphae. Use of 10% KOH in wet preparations improves the visualization of yeast and mycelia by disrupting cellular material that might obscure the yeast or pseudohyphae. Click her to go back Click here to move on

16. Budding yeasts and Pseudohyphae The morphology is typical of actively growing Candida sp. This slide is also typical of one that has been allowed to ‘incubate’ at room temperature for about 3 hours so that the yeast cells tend to swell. Fresh specimens do not typically exhibit such luxurious growth and vacuolated yeast cells. Budding yeast Pseudohyphae Click her to go back Click here to move on

17. Budding yeasts and Pseudohyphae Low Power Click her to go back Click here to move on

18. Click her to go back Click here to move on

19. These are fragile tube-like structures that arise through elongation of the yeast form of Candida. Pseudohyphe may demonstrate a terminal swollen remnant of the original yeast cell. They are called pseudohyphae because they lack true branching as seen with mold like fungi. The side walls are parallel to each other which is an important characteristic that helps separate pseudohyphae from artifact whose side walls vary in width. Small oval structures called bastoconidia are often seen attached along the length of the pseudohyphae. The blastoconidia are smaller in size when compared to the yeast form of Candida. While pseudohyphae are usually seen along with yeast cells or budding yeast, it is also possible to see pseudohyphae in the absence of yeast cells. Pseudohyphae with budding yeast cells Pseudohyphae Click her to go back Click here to move on

20. Budding yeast Trichomonads Clue Cells Pseudohyphae Click here to select this answer Click here to select this answer Click here to select this answer Click here to select this answer Click her to go back

21. Pseudohyphae Click her to go back Click here to move on

22. Artifact vs. Pseudohyphae One of the more troublesome artifacts is fibers that are sometimes confused with pseudohyphae. There are a few tips that may help in the differentiation. 1. Fibers are generally larger in size that pseudohyphae 2. Pseudohyphae have parallel sides with a consistent dimension between the sides while fibers show variable widths along the fiber. 3. Fibers tend to be birefringent. That is they change color when focusing up and down on the object. Colors are often gold or blue and result from the microscope light being refracted by the fiber. Click her to go back Click here to move on

23. Trichomoniasis is caused by the protozoan T. vaginalis. Many infected women have symptoms characterized by a diffuse, malodorous, yellow-green vaginal discharge with vulvar irritation. However, some women have minimal or no symptoms. Diagnosis of vaginal trichomoniasis is usually performed by microscopy of vaginal secretions, but this method has a sensitivity of only approximately 60%–70% and requires immediate evaluation of wet preparation slide for optimal results. Click her to go back Click here to move on

24.  Trichomonas are parasitic protozoa.  They can be very motile  When they begin to die (within 10 minutes of specimen collection), they become sedentary and begin to round up.  Trichomonas should only be reported when motility is observed Click her to go back Click here to move on

25. True False Click here to select this answer Click here to select this answer Click her to go back

26. False…….Trichomonas begin to die about 10 minutes after specimen collection. Therefore, it is imperative that the specimen be processed quickly following collection. Click her to go back Click here to move on

27. Click her to go back Click here to move on

28.  Trichomonas have a very complex structure.  They have four flagella facing ‘forward’ and a fifth facing ‘backward’ which is attached to an undulating membrane.  The cells are oval in shape, 10-23 µm in length Click her to go back Click here to move on

29.  Appearance of a “strawberry cervix” may be seen with Trichomonas infection Click her to go back Click here to move on

30. Must have 3 of the 4 signs for a diagnosis of BV (AMSEL’S CRITERIA) Discharge, white & homogeneous Elevated pH, >4.5 Amine odor present 20% clue cells present on wet mount Click her to go back Click here to move on

31. Click her to go back Click here to move on

32.  Gardnerella vaginosis (small, gram negative [red] rounded rods - coccobacilli)  Mobiluncus sp. (small, slender gram negative [red] curved rods).  Both are normally found in the vagina (i.e., normal flora)  In bacterial vaginosis, these bacteria increase in number and degrade proteins in the vagina to form the amines that cause the characteristic unpleasant odor associated with BV. Click her to go back Click here to move on

33. True False Click here to select this answer Click here to select this answer Click her to go back

34. True…….The vaginal pH of greater than 4.5 is characteristic of BV. This is an alkaline state. Additional criteria (other than an elevated pH) are needed to make a diagnosis of BV. Click her to go back Click here to move on

35. CLUE CELLS Clue cells are squamous epithelial cells that are covered with a thick matte of bacterial cells and are associated with bacterial vaginosis. The traditional definition of a clue cell is that the bacterial overgrowth is so thick that all cellular detail (such as the cell nucleus and the cellular edge) is totally obscured. It is sometimes possible to detect the nucleus in a clue cell by using the fine focus knob to focus throughout the cell. SQUAMOUS EPITHELIAL CELLS The cell nucleus and the cell boundary are clearly observed. Click her to go back Click here to move on

36. CLUE CELL SQUAMOUS EPITHELIAL CELLS Click her to go back Click here to move on

37. Low Power Clue cell Squamous Epithelial cell – not a clue cell Click her to go back Click here to move on

38.  The bacteria shown in this slide are characteristic of lactobacilli, which is normal flora in women following the onset on menses and will persist as normal flora until menopause. Click her to go back Click here to move on

39. Once you are confident that you are comfortable with all the materials presented, proceed to the Vaginal pH and Wet Mount Testing post test at http://www.classmarker.com/professional/ Your username is the first initial of your first name followed by your full last name. Your password is= nwhealth Click here to go back and review previous slide Start OverExit Click here to link to CDC free CME/CNE on vaginitis and STDs