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Chlamydia and gonorrhea screenings documented as performed (HIV)

CPT4 code

Name of the Procedure:

Chlamydia and Gonorrhea Screenings (HIV) Common name(s): STD Testing, STI Screening

Summary

Chlamydia and gonorrhea screenings are medical tests used to detect the presence of these two sexually transmitted infections (STIs). These screenings are particularly emphasized for individuals who are also at risk for or diagnosed with HIV, due to the interrelated health impacts.

Purpose

The purpose of these screenings is to diagnose chlamydia and gonorrhea infections early, which is crucial for treatment and preventing complications. These infections can exacerbate the health complications of individuals living with HIV and can be transmitted to sexual partners, making early detection and treatment essential.

Indications

  • Unusual discharge from the penis or vagina
  • Painful or frequent urination
  • Pain during intercourse
  • Sore throat (if the infection is oral)
  • Patients diagnosed with HIV, given their increased susceptibility to STIs
  • Routine screening for sexually active individuals, especially those with multiple sexual partners

Preparation

  • No specific preparation is generally required.
  • Patients may be advised to avoid urination for a certain period (e.g., 1-2 hours) before the sample collection for urine tests.

Procedure Description

  1. Sample collection: A healthcare provider collects bodily fluid samples. This can be done through a urine sample, a vaginal swab for women, or a urethral swab for men.
  2. Laboratory Analysis: The collected samples are sent to a lab where they are analyzed for the presence of Chlamydia trachomatis and Neisseria gonorrhoeae bacteria.
  3. Results: Test results are typically available within a few days to a week.

Duration

The sample collection process typically takes less than 15 minutes.

Setting

The procedure is performed in various settings, including outpatient clinics, hospitals, sexual health clinics, and sometimes at-home testing kits are available.

Personnel

  • Healthcare provider (e.g., nurse, doctor, or trained technician) for sample collection.
  • Lab technicians for sample analysis.

Risks and Complications

  • Minimal risks involved, primarily minor discomfort during sample collection.
  • Rare chance of minor bleeding or infection if a swab is used.

Benefits

  • Early detection of chlamydia and gonorrhea, allowing timely treatment.
  • Reduces the risk of complications and transmission to partners.
  • Helps in the comprehensive management of HIV and general sexual health.

Recovery

  • No recovery time is needed for the screening itself.
  • Follow-up care may include antibiotic treatment if the test results are positive.
  • Avoid sexual activity until infection is confirmed to be fully treated.

Alternatives

  • Visual examination or patient history, which are less reliable.
  • At-home testing kits, which provide privacy but may require follow-up with a healthcare provider for confirmation and treatment.
  • Combined STI screening tests that include other common infections.

Patient Experience

  • The procedure is usually quick and causes minimal discomfort.
  • If a swab is used, the patient might feel a brief discomfort or pressure.
  • Pain management is generally unnecessary due to the non-invasive nature of the screening.
  • Patients may experience anxiety or nervousness about the results, but healthcare providers offer support and counseling if needed.

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