The most important aspect of the diagnosis of STDs is to maintain a high level of awareness. While many patients may present with an obvious STD (lesion on the penis), more commonly the chief complaint may be as vague as dysuria or lower abdominal pain. For example, a study at an inner-city ED suggested that half the patients who were discharged with a diagnosis of urinary tract infection (UTI) had one or more positive STD cultures.
Once a physician suspects an STD, obtaining a history of sexual activity and previous STDs is important. This may clue the physician into examining or culturing oral or anal areas, help differentiate mechanical from infectious lesions, and predict risk for hepatitis and HIV infections. Questions about pregnancy and sexual assault should asked, if appropriate. These questions can be asked in a nonconfrontational manner by explaining to the patient their rationale.
Careful examination of the genital areas (and pelvic examination in women) is important. The foreskin should be retracted, if present, and the physician should be sure to look in skin folds and other areas that may not be readily viewable, particularly in obese persons. Cultures for gonorrhea and chlamydia should be taken if there is a suspicion of STDs to document the infection. Other tests may be appropriate for specific lesions.
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