Elizabeth Katz

CUNY York PA – S

Chief complaint: “rash x 3 days”

HPI

31 y.o. M no PMH presents as a walk-in c/o rash, swollen gland on right side of groin, and an STD screening. He states that the rash is spread all across his body and began three days ago. It does not itch, there are no aggrevating or alleviating factors, and he has not taken anything for it. He first noticed the swollen gland in his groin 2 weeks ago, but states it is nontender and he did not think much about it until the rash began. He reports sex with men and women, but denies receptive anal sex, with inconsistent condom use. His last STD screening was in August of 2018 and he states that it was normal. He denies any hx of STI, penile lesion, penile discharge, dysuria, hematuria, frequency, urgency, nocturia, fever, chills, headache, malaise, N/V, change in bowel habits, weight loss, or myalgias. He endorses recent travel to India December 2018 – January 2019. He is also interested in initiating pre-exposure prophylaxis.

DDx:

• HIV: diffuse rash, sexual hx, lymphadenopathy, PREP interest
• Syphilis: diffuse rash, sexual history, lymphadenopathy, uncircumsized

PMH

none

PSH

none

Medications

none

Allergies

NKDA

FHX

Grandfather: colon cancer, deceased at 77

Mother: alive and well

Father: HLD, alive and well

SHX

He is unmarried and lives with two roommates. He reports occasional alcohol use and regular marijuana use, but denies smoking or other illicit drug use. He recently traveled to India (December 2018 – January 2019).

ROS

• Constitutional: mild fatigue but weight remains stable at 168lbs
• HEENT:
• Occasional headaches, well-controlled with OTC medications
• Eyes: no recent changes in vision, photophobia, or glasses use
• Ears: hearing intact
• Nose: no epistaxis or obstruction
• Mouth and throat: no ulceration, hx of candidiasis, no recent dental visit
• Neck: no adenopathy, localized swelling or stiffness
• Respiratory: No SOB, cough, wheezing, hemoptysis, PE, pneumonia, TB or TB exposure
• Cardiac: no recent chest pain, palpitations, edema of hands or feet, syncope, known murmur
• Vascular: no hx of claudication, gangrene, DVT, aneurysm
• GI: BS+, denies abdominal pain, N/V, change in bowel habits or BRBPR
• GU: denies urinary frequency and urgency, dysuria, polyuria, hematuria, or nocturia
• Hematological: no known blood or clotting disorders
• Rheumatic: no hx of gout, rheumatic arthritis, or lupus
• Dermatological: diffuse rash that began two days ago

PE

• VS: BP 132/83 right arm, sitting position; pulse 74 regular; O₂sat 99% room air; respirations 16/min; temp 99°F oral; weight 168 lbs
• Patient is alert and oriented x 3, appears stated age and is resting comfortably
• HEENT: normocephalic atraumatic
• Eyes: sclera and conjunctiva clear, EOMs full, PERRLA
• Neck: trachea midline, carotids 2+ b/l
• Heart: regular rate and rhythm, no heaves, gallops, murmurs
• Lungs: clear to ausculation bilaterally, no retractions, wheezes, ronchi, or consolidation
• Abdomen: soft, nontender to palpation, no CVA tenderness
• GU: uncircumsized male no lesions or discharge noted, no testicular masses or edema, firm enlarged right inguinal lymph node, mildly tender to palpation
• Extremities: no edema or tenderness in LE b/l, distal pulses intact, ROM intact b/l
• Skin: moist, good turgor, cap refill < 2 sec, diffuse erythematous mildly scaly macular rash noted that crosses the palm of the left hand and soles of feet bilaterally

Labs

• STI screening: T. pallidum Abs, IgG/IgM REACTIVE; RPR confirmatory REACTIVE; RPR titer 1:64
• UA: trace protein

DDx:

• Syphilis
• HIV
• Coxsackie virus: unlikely given the lack of viral prodrome or oral ulcers

Assessment: 31 y.o. M no PMH present c/o rash and inguinal adenopathy T. pallidum positive and confirmatory RPR with secondary syphilis.

Plan

• Penicillin G benzathine 2.4 mU IM x 1
• RTC in 6 and 12 months for retesting

Patient education: Syphilis is a sexually transmitted infection and typically begins as a painless sore or ulcer on your genitals it then progresses in stages. You have stage two syphilis and it can be treated by the medication we have prescribed. When you take the medication to treat the syphilis you may experience a fever accompanied by headache, muscle pain, chills sweating and worsening of the rash. This reaction occurs in about 10-35% of people treated for syphilis, it generally occurs within the first 24 hours of taking the medication and often goes away in about 12-24 hours on its own. You can take ibuprofen to help with the symptoms, if it is severe you can call us or go to the emergency room. It is also very important that you contact any recent sexual partners and inform them of your diagnosis so that they can be treated. Additionally, the consistent and correct use of condoms is highly effective in preventing HIV as well as other sexually transmitted infections.