Assessment

HISTORY. Although sexual activity is potentially a sensitive topic, it is critical to obtain a detailed sexual and gynecologic history. Inquire about the number of partners, use of barrier protection and birth control measures, participation in oral or anal intercourse, and previous STIs. Most patients who present with C. trachomatis have a history of multiple sex partners and engaging in sexual intercourse without the use of barrier protection. Often, patients are also positive for gonorrhea. Inquire if the patient has any thin or purulent discharge, burning or frequent urination, mucus-covered stools, lower abdominal pain, dyspareunia (painful sexual intercourse), headache, nausea, vomiting, chills, or bleeding after intercourse. Often, patients are asymptomatic, and some may complain only of an increase in vaginal discharge. Male patients may report dysuria, urinary frequency, and pruritus. Ask the patient if she or he is experiencing any diarrhea, tenesmus, or pruritus, any of which indicates that the infection involves the rectum.

PHYSICAL EXAMINATION. For females, inspect the vagina, cervix, and labia and note any mucopurulent discharge. Bartholin glands may be involved. Gently touch the cervix; note any bleeding (friable cervix). Inspect males for purulent discharge at the urinary meatus. Scrotal swelling occurs if the organism has caused epididymitis. Inspect the anus for discharge and excoriation. If LGV is present, ulcerative lesions on the cervix, vagina, labia, anal/rectal area, or penis may occur. Enlarged lymph nodes also can be palpated in the groin. If these nodes rupture, they secrete a thick yellow granular substance.

PSYCHOSOCIAL. Assess the patient's knowledge of STIs and the implications. Assess the patient's ability to cope with having an STI. The diagnosis of an STI can be very upsetting to a male or female who believes he or she was involved in a monogamous relationship. Patients may feel embarrassed and guilty about their condition. Inquire about the patient's ability to obtain condoms. Identify all partners with whom the patient has been sexually active so that they can be examined and treated. Assess the patient's support system; this is especially important if the patient is pregnant.

Diagnostic Highlights

General Comments: Enzyme-linked immunosorbent assay (ELISA) and antigen detection by direct fluorescent antibody slide staining are less expensive tests to diagnose chlamydia. Until recently, a tissue culture was the gold standard to diagnose chlamydia, with a sensitivity of approximately 85%. Currently, more widespread use of nucleic acid amplification tests (NAATs) have been used; although more costly, these tests have an increased sensitivity, and are more comfortable to obtain since the preferred specimen is a first-void urine. Because of fetal implications, most pregnant women are screened for chlamydia.

Test

Normal Result

Abnormality with Condition

Explanation

Cervical tissue culture (females); urethral tissue culture (males)

Nucleic acid amplification tests (NAATs)

Negative culture Positive culture

Negative

Positive signal

Growth of the organism confirms the diagnosis

Detects Chlamydia from DNA/RNA presence

Other Tests: Since symptoms of gonorrhea resemble a chlamydial infection, diagnosis is often made on the basis of a symptomatic patient with a negative gonorrhea culture.

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