Chief complaint: Rash on penile shaft X 5 days
HPI:
23 y/o male with no reported PMHx presents to the urgent care today for a follow-up visit. He was seen 5 days ago with a rash on his penis that was further characterized by burning and itching, but he denied any discharge. The rash was noted to be moist and was not yet dry or crusted over. Pt reports he had unprotected sex with one female partner before he came to the office 5 days ago. On that office visit, he was tested for STDs, and the results revealed a positive HSV 2 Glycoprotein G Ab, and a reactive RPR. He was prescribed Valtrex 1 GM tablets, which he has been taking as directed but feels like it has not been effective and still has the rash. Pt denies any past history of STDs or genital discharge. Pt. also denies headache, fever, chills, dysuria, hematuria, cough, nausea, abdominal pain, diarrhea, constipation, or vomiting.
Past Medical History
None
Past surgical history
None
Medications
Valtrex 1 GM by mouth twice daily for seven days
Allergies
– NKDA
– Food allergy: None
– Denies seasonal allergies
Family history
– Father – deceased
– Mother – alive and well
Social History
Habits: denies drinking alcohol, smoking cigarettes, or using illicit substance abuse.
Travel: Pt has not traveled recently
ROS
General – Denies fever, fatigue, weakness, or weight loss
Skin, Hair, Nails – denies any change in hair texture, excessive dryness or sweating, discolorations, pigmentations, rashes, or pruritus
Head – denies losing unconsciousness, headache or being lightheaded currently.
Eyes – Denies visual disturbances, blurry vision, fatigue, photophobia, lacrimation, or pruritus.
Nose/sinus – denies obstruction, discharge, or epistaxis.
Ears – denies deafness, pain, discharge, tinnitus, or hearing aids.
Mouth/throat – denies bleeding gums, sore tongue, mouth ulcers, voice changes or denture use.
Neck – denies localized swelling/lumps or stiffness/decreased range of motion.
Breast – denies lumps, nipple discharge, or pain.
Pulmonary system – Denies orthopnea, dyspnea, wheezing, hemoptysis, cyanosis, cough, paroxysmal nocturnal dyspnea.
Cardiovascular system – Denies palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur, chest pain or hypertension.
Gastrointestinal system – Denies vomiting, decreased appetite, pyrosis, flatulence, eructation, flank pain, diarrhea, jaundice, change in bowel habits, constipation, abdominal pain, pelvic pain, rectal bleeding, or dysphagia
Genitourinary system – Admits to painless and non-itchy rash on shaft of penis. Denies incontinence, change in urine color, polyuria, dysuria or nocturia
Menstrual/obstetrical – N/A
Nervous – Denies weakness, sensory disturbances, or seizures.
Musculoskeletal system – Denies redness, back pain, arm pain, swelling or arthritis.
Peripheral vascular system – denies intermittent claudication, trophic changes, varicose veins, peripheral edema, or color changes.
Hematologic system – denies easy bruising and bleeding, anemia, lymph node enlargement, blood transfusions, or h/o DVT/PE.
Endocrine system – denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.
Psychiatric – Denies helplessness or hopelessness, anxiety, depression, and a history of seeing a mental health professional, lack of interest in usual activities, suicidal ideation, or OCT.
Physical Exam
General: Male in his 20’s is awake, alert, and oriented x 3 and in no acute distress. He is dressed appropriately for the weather and has a good affect and mood.
Vital signs:
– BP: L: 134/72 mm/Hg
– Respiratory rate: 17 breaths/min, unlabored
– Pulse: 65 beats/min, regular
– Temperature: 98.1 degrees F (oral)
– O2 sat: 98% room air
Skin – No bruising was noted on the patient. Good turgor. No tenting. Normal body temperature was noted. Non-icteric
Hair – Average quantity and distribution.
Nails – No clubbing was seen; cap refill was under 2 seconds. No splinter hemorrhages, lesions, swelling nor any beau’s lines were noted. Atraumatic.
Head – Normocephalic, atraumatic and non-tender to palpation.
Eyes – Symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctive pink.
Ears – Symmetrical and appropriate in size. No lesions, masses or trauma on external ears. No discharge, bleeding or foreign bodies in external auditory canal AU.
Nose – Symmetrical nares with no masses, lesions, deformities, trauma or discharge. Nares patent bilaterally. Nasal mucosa pink. No discharge noted on anterior rhinoscopy. Septum midline without any lesions, deformities or perforation. No foreign bodies.
Lips – Pink, moist with no cyanosis or masses noted. Non-tender to palpation.
Oral Mucosa – Pink and well hydrated. No masses, lesions or leukoplakia noted.
Palate – Pink and well hydrated. No masses or lesions noted.
Teeth – Good dentition with a couple of filled cavities noted.
Gingivae – Pink and moist. No hyperplasia or masses.
Tongue – Pink, well papillated. No masses, lesions or deviation noted.
Oropharynx – Well hydrated with no erythema, exudates, masses, or lesions. Tonsils are present with no erythema or exudates. Uvula midline with no lesions noted.
Neck – Trachea midline. No masses, lesions, or scars noted. Supple and non-tender to palpation. Full range of motion. No palpable cervical adenopathy.
Thyroid – Non-tender, no thyromegaly. No palpable nodules nor any bruits noted.
Chest – Symmetrical, no deformities and no trauma noted. Respirations unlabored / no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation throughout
Lungs – Symmetrical expansion with respiration. No intercostal retractions, or tenderness. Breath sounds clear to auscultation bilaterally. No rales/wheezes/rhonchi auscultated.
Heart – Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.
Abdomen – Non-distended, soft and non-tender. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. No palpable masses or organomegaly. No inguinal hernia. No palpable lymphadenopathy. Costovertebral angle nontender.
Genitourinary: Shaft of the penis has multiple concentric ulcerated lesions and patient is uncircumcised. Right and left testes do not have a mass present nor have any tenderness, swelling, hydrocele or varicocele. Right and left testes are descended. Cremasteric reflex is present for both testicles.
Mental status exam: Patient is well appearing, has good hygiene, and is neatly groomed. Patient is alert and oriented to name, date, time and location. Speech and language ability intact, with normal quantity, fluency, and articulation. Patient denies changes to mood. Conversation progresses logically. Insight, judgement, cognition, memory, and attention intact.
Motor/Cerebellar: Full active/passive ROM of all upper and lower extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors, or fasciculation. Strength 5/5 of both upper and lower extremities. Rhomberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, and no asterixis
Peripheral Vascular: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally. No stasis changes or ulcerations noted. No calf tenderness bilaterally, equal in circumference. Homan’s sign not present bilaterally. No palpable cords or varicose veins bilaterally. No palpable inguinal or epitrochlear adenopathy.
DDX:
Primary syphilis
Genital warts
Chancroid
Assessment:
23 y/o male presents to the urgent care today for a follow-up 5 days after being at this office for a positive HSV and RPR tests. Concentric ulcerations were found on exam on the shaft of the patient’s penis.
Plan: Since the lab work was already done for the patient that showed the positive RPR and the multiple chancres were noticed on exam, Bicillin L-A (Penicillin G Benzathine) suspension, 2.4 million units was ordered and administered via injection into the left gluteus maximus.
