Clinical Manual for Management of the HIV-Infected ... - myCME.com

6–34 | Clinical Manual for Management of the HIV-Infected Adult/2006
O: Objective
Physical Examination
During the physical examination, check for fever and
document other vital signs.
In women, focus the physical examination on the
mouth, abdomen, and pelvis. Inspect the oropharynx
for discharge and lesions; check the abdomen for bowel
sounds, distention, rebound, guarding, masses, and
suprapubic or costovertebral angle tenderness; perform a
complete pelvic examination for abnormal discharge or
bleeding; check for uterine, adnexal, or cervical motion
tenderness; and search for pelvic masses or adnexal
enlargement. Check the anus for discharge and lesions;
perform anoscopy if symptoms of proctitis are present.
Check for inguinal lymphadenopathy.
In men, focus the physical examination on the mouth,
genitals, and anus/rectum. Check the oropharynx
for discharge and lesions, the urethra for discharge,
the external genitalia for other lesions, and the
anus for discharge and lesions; perform anoscopy if
symptoms of proctitis are present. Check for inguinal
lymphadenopathy.
A: Assessment
A partial differential diagnosis includes the following:
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Urinary tract infection
Dysmenorrhea
Appendicitis
Cystitis
Proctitis
Pelvic inflammatory disease (PID)
Irritable bowel syndrome
Pyelonephritis
P: Plan
Diagnostic Evaluation
Test for oral, urethral, or anorectal infection, according
to symptoms and possible exposures. Perform
concurrent testing for both gonorrhea and chlamydia.
The availability of the various testing methods depends
on the clinical site. Consider the following:
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Gram stain (pharyngeal, cervical, or urethral
discharge)
Culture (oropharynx, endocervix, urethra, rectum)
Nucleic acid amplification test (NAAT): urine
specimens (first stream) and urethral, vaginal, and
endocervical swab specimens; has also been used for
pharyngeal and rectal swab specimens, although it is
not currently approved for this use
Nucleic acid hybridization assay (DNA probe):
endocervical and male urethral swab specimens
Serologic tests (microimmunofluorescence test or
complement fixation test) for suspected LGV
Treatment
Treatments for gonorrhea and chlamydia are indicated
below. High rates of fluoroquinolone-resistant N
gonorrhoeae exist in California, Hawaii and the Pacific
Islands, Asia, and Great Britain. Fluoroquinoloneresistant
GC is also common among MSM in the
United States. Thus, the U.S. Centers for Disease
Control and Prevention (CDC) recommends that
fluoroquinolones not be used for treatment of GC
in MSM or in any patient infected in the areas listed
above, unless antimicrobial susceptibility test results are
used to guide therapy.
Because dual infection is common, patients diagnosed
with either GC or CT should receive empiric treatment
for both infections, unless the other infection has been
ruled out. Reinfection is likely if reexposure occurs. Any
sex partners within the last 60 days, or the most recent
sex partner from >60 days before diagnosis, also should
receive treatment. Patients should abstain from sexual
activity for 7 days after a single-dose treatment or until
a 7-day treatment course is completed.
Adherence is essential for treatment success. Singledose
treatments maximize the likeliness of adherence
and are preferred. Other considerations in choosing
the treatment include antibiotic resistance, cost,
allergies, and pregnancy. For further information, see
the CDC STD treatment guidelines and the revised
recommendations (references below).