Date: 8/10/20

Patient Name: DJ

CC:  penile discharge x 6 days

30 yo African-American male with PMH of G6PD deficiency and recurrent STDs presents for penile ulcers and penile discharge. Pt complains of white/ yellow thin penile discharge, which is at times green and has been recurrent over the past couple months with periods of  remission. Pt reports the discharge reoccurred 6 days ago, shortly after last unprotected sexual encounter with long-term male partner. Pt also has been complaining of dysuria, specifically burning within his urethra which is worsened after sex. Pt also complains of a bilateral “shooting” sensation from his lateral lower abdomen radiating down to his groin since January, which is a 4/10 in severity and occurs randomly. Pt denies any alleviating or aggravating factors or taking anything for the pain. Pt reports he decided to come in today because he noticed a small painful, penile ulcer and is concerned for syphilis. Pt reports that he tested positive for syphilis 1.5 years ago and was treated with penicillin IM. Pt reports he gets tested for STDs regularly and his RPR has been within normal limits for the past few months in the past two STD tests. Pt reports he visited his PCP 3 months ago for similar symptoms and was treated for gonorrhea/ chlamydia with Doxycycline for 20 days. Pt reports his symptoms have caused him distress as he has been repeatedly treated but reports his symptoms such as dysuria, dyspareunia, and discharge have never fully gone away, although he does experience periods without remission. Pt reports he has one male partner, his partner of two years, since January, but both have been sexually active with other people prior to January. Pt reports they have unprotected sex only and both have a history of STDs. Pt reports partner is experiencing similar symptoms and has gone to be treated at a different urgent care. Pt denies rash, sore throat, hematuria, oliguria, dizziness, confusion, changes in mental status, lymphadenopathy, f/n/v/d/ chest pain, anorexia, myalgia, unintentional weight loss, presence of gummas or genital vesicles, headache, paresthesias, weakness, new medications.

PMH

Current illnesses: G6PD Deficiency

Past Illness: Gonorrhea, Chlamydia, Syphilis

Surgeries: None

Allergies: NKDA

Medications: None

Trauma/Injuries: None

 

Social History

Education: Bachelor’s Degree in Art

Military: None

Work/finances: Works as an artist and is heavily involved in community affairs, painting murals with community children.

Family & relationships: Lives with boyfriend in Brooklyn apartment. Long-term relationship with boyfriend. Unmarried, no children.

Habits/risk factors: Denies tobacco and alcohol use. Smokes marijuana daily.

Reproductive History: Reports being currently sexually active with one male partner currently and denies using protection with partner but uses protection with others. Pt reports he has been in a relationship with partner for 2 years and has been sexually monogamous with partner since January, whereas prior both had multiple male sexual partners. Pt reports both him and his partner have a history of STDs, with the patient reporting a personal history of gonorrhea, chlamydia, and syphilis, but denies history of any other STDs. Pt reports engaging in oral and anal sex.

 

Family History

Mother: 60, alive and well

Father: 62, DM, HTN

Sister- 28, alive and well

Denies family history of cardiac problems or cancer.

 

ROS:

General: Denies fever, chills, fatigue, recent weight loss.

HEENT: Denies vision changes, eye pain, heartburn, nasal/ ear discharge, ear pain, sore throat.

Lymph nodes: Denies swollen lymph nodes in neck, axilla, or inguinal area.

Respiratory: Denies dyspnea, wheezing, cough, sputum, hemoptysis.

Cardiovascular: Denies chest pain, palpitations, syncope, dyspnea on exertion, known murmur/ arrhythmia.

Gastrointestinal: Reports lower flank pain that radiates into groin. Denies nausea, vomiting, diarrhea, constipation, hematochezia, change in bowel movements, rectal bleeding.

Genitourinary: Reports yellow/ white thin penile discharge, dyspareunia, dysuria, and penile ulcers. Reports history of gonorrhea, chlamydia, and syphilis in the past two years. Denies hematuria, polyuria, nocturia, testicular pain/ swelling, scrotal mass, erectile dysfunction, rectal lesions, change in libido.

Musculoskeletal: Denies joint pain/ stiffness/ swelling and myalgia.

Skin: Denies itching, rash.

Neuro:  Denies paresthesia, headaches, dizziness, change in cognition, confusion, loss of memory.

Psychiatric: Reports being distressed by recurrent symptoms but denies anxiety, depression, changes in mood, or ever seeing a mental health professional.

 

Physical Exam

VS: BP: 113/72  P: 81  RR: 16 T: 98.7  degrees F O2Sat: 97%

Ht: 5’7 Wt: 136 BMI: 21.3

 

General: Pt is a slender, well-developed male and looks stated age of 30. He is sitting on the exam table and appears to be in mild emotional distress. AOx3.

Skin: Warm and moist. No rash, suspicious lesions (besides for penile ulcers, see GU exam), masses, pallor, or cyanosis.

Mouth: No erythema, ulcers, or exudates in oropharynx. No tongue deviation, uvula midline, gums are pink.

Neck: Trachea midline. No lymphadenopathy or stiffness of neck.

Cardiovascular: RRR. S1, S2 normal. No murmurs/ gallops/ rubs.

Respiratory: CTA bilaterally. No wheezing/ rales/ crackles.

Gastrointestinal: Non-tender to light and deep palpation, including in aforementioned area. Soft,  non-distended, no masses. BS present. No guarding or rigidity.
Genitourinary:  two approximately 0.5 mm ulcers present on penis shaft. Ulcers are tender to palpation. No penile discharge or bleeding, testicular tenderness, erythema noted. No inguinal/ femoral hernias or other masses noted. Chaperoned by scribe.
Neuro: Alert and oriented. Mental status articulate.
Extremities: no clubbing, cyanosis, or edema.
Psychiatry: Pt appears mildly emotionally distressed by symptoms. Pt cooperative with exam. Normal speech. Good eye contact.

Assessment: DJ is a 30 year old male with PMH of G6PD deficiency and recurrent STDs presenting with penile discharge, penile ulcers, abdominal pain, and dyspareunia/ dysuria consistent with presence of multiple STDs. Pt likely has a combination of gonorrhea, chlamydia, and syphilis based on MSM status, past history, presence of discharge, and penile ulcers.

 

Plan:

1. Treat empirically for gonorrhea and chlamydia based on penile discharge and history with 250 mg ceftriaxone IM once and 1 g azithromycin PO once.
2. Perform complete STD panel
   1. Syphilis- RPR; if negative, confirm, with FTA-ABS
      2. If positive, treat as early syphilis with 2.4 million units Penicillin benzathine G IM
   2. Herpes- HSV PCR
      1. No treatment needed as no active outbreak; If there was an outbreak, treat with PO valacyclovir 1000 mg BID for 7 days
   3. Hepatitis B- HBV surface antigen (HBsAg), surface antibody (HBsAb), and core antibody (HBcAb)
      1. If positive, refer to GI or hepatologist
   4. Hepatitis C- HCV antibody
      1. If positive, refer to GI or hepatologist
   5. Gonorrhea/ chlamydia- urine NAAT and oropharyngeal and rectal swabs
      1. Already empirically treated.
   6. Trichomoniasis- urine NAAT
      1. If positive, 500 mg PO Flagyl BID x 7 days. Avoid alcohol use while taking Flagyl.
   7. HIV PCR
      1. If positive, refer to HIV clinic
   8. Advise pt to return in one week when results return and to monitor for improvement/ resolution of symptoms.
   9. Since partner is currently being treated at another urgent care, call patient tomorrow to ensure partner was treated as well.
   10. Advise pt to abstain from sex until complete symptom resolution.
   11. Encourage pt to get STD testing periodically at 3 month intervals.
   12. Educate patient on importance of using protection and safer sex practices, and high risk status as a homosexual male.

Differentials:

1. Gonorrhea- Likely because of discharge, dysuria, risk factors, and hx of gonorrhea.
2. Chlamydia- Likely because of color and consistency of discharge, dysuria, risk factors, and hx of chlamydia.
3. Syphilis- Likely because of history of syphilis and penile ulcers, as well as high prevalence within the MSM group. Some inconsistencies include that there are two ulcers and they are painful, however not enough to rule out syphilis without testing. No rash or flu-like symptoms pointing to secondary syphilis.
4. Genital herpes- consistent with presence of multiple lesions, but unlikely as these are not grouped vesicles but two isolated ulcers.
5. Chancroid- Consistent with multiple painful ulcers. Highly unlikely as very low prevalence in the US and inconsistent with size of lesions.
6. Trichomoniasis- consistent with dysuria but inconsistent with discharge consistency. Unlikely because low rates of transmission among homosexual men.

Syphilis_Liu

Comparison of efficacy of treatments for early syphilis: A systematic review and network meta-analysis of randomized controlled trials and observational studies
Hong-ye Liu1,2, Yan Han1, Xiang-sheng Chen1, Li Bai2, Shu-ping Guo2, Li Li2, Peng Wu3,
Yue-ping Yin1* (2017)

According to the WHO, 90% of the 12 million of the yearly new syphilis cases occur in developing countries, however there has been a rise of syphilis cases in the US, often among the MSM population. Untreated syphilis can also result in increased susceptibility to contracting HIV. IM penicillin is first-line for syphilis however alternates are important to consider for penicillin-allergic patients and any reason that warrants PO rather than parenteral administration.

This article is a systematic review and meta-analysis comparing the efficacy of the standard early syphilis treatment, penicillin, to alternatives, namely ceftriaxone and doxycycline or tetracycline. The analysis included three RCTs and seven cohort studies for a total of 2049 patients. At 12 months, there was no significant difference in serological response rate between penicillin, ceftriaxone, and tetracycline/ doxycycline, however tetracycline/ doxycycline did have a higher serological treatment failure rate compared to ceftriaxone and penicillin, with a relative risk ratio of treatment failure of 0.58 comparing penicillin to tetracycline/ doxycycline. The article warrants further research as the population of patients taking the alternates was small (115 patients treated with ceftriaxone, 267 treated with doxycycline or tetracycline) compared to the 1667 patients treated with penicillin.

 

 

Site Reflection

For my first evaluation, I presented two H&Ps on costochondritis and gastritis and presented one H&P on STDs and a journal article for my second site evaluation. For my site evaluations, the feedback received was positive overall with some adjustments made to my plans. For example, for my costochondritis case, I opted for PO pain relief via ibuprofen but it was recommended to also add in a topical analgesic, such as IcyHot. For my STD case, since the patient had a history of multiple STDs as well as symptoms that have never fully resolved and likely had several STDs at the time of presentation, I was advised that the patient should be referred to Infectious Disease as this is a more complex case. For my site evaluations, I think I have definitely improved since the beginning of clinical year, as my H&Ps have been more thorough, as I often forgot to ask certain important questions in my H&P. I would not change much for future site visits, but continue to try to pick the most complex and interesting patients for my H&Ps.

Rotation Reflection

I really enjoyed my Urgent Care rotation at Statcare. It was a great environment and I felt this was the rotation where I learned the most. The knowledge and skills I have learned in this rotation will be very useful for me on other rotations. I was able to practice a lot of IM and subcutaneous shots, blood draws, nasal swabs, sutures, and history and physicals. Ironically, COVID improved my experience as there were plenty of opportunities for blood draws as a result of the constant flow of antibody testing we were performing.  I was especially happy to really improve on blood draws as this was always an area in which I did not feel comfortable doing without supervision. Furthermore, this will help me help the team on my next rotations. Overall, I was able to practice skills even more on this rotation than my Emergency Medicine rotation, as there were no nurses to do many of the tasks and thus more opportunity to do so as a student. 

One procedure I both greatly improved in but also struggled with is sutures. I have learned to be comfortable doing typical sutures, however I struggle with patients with lots of swelling to the area, lots of bleeding, or thicker skin. Furthermore, I struggle more with sutures around the fingers. This is something I hope to continue to practice by myself using my suture kit as well as suturing in general during my surgery rotation. I have also gotten to see a lot of suture follow-ups, with several that did not hold up over the next few days. These patients helped me to pay special attention to what suture material to use, whether the area warrants staples instead, and if any reinforcers should be used as an adjunct, such as steri strips. 

This experience helped give me a perspective on important things to consider when working in an urgent care setting. Urgent cares receive similar cases to the ER fast track but with much less resources. It is important to be cognizant of what should be managed in the urgent care and what should be sent to the ER. For example, one provider was commenting on how another provider ordered  d-dimer. She was explaining it was not wise, as if the provider thought the patient had potential for a pulmonary embolism, the patient should be sent to the ER. A d-dimer sent from an urgent care will not come back before a few days, which is practically useless at that time. Another skill I learned based on this perspective is how to differentiate between what chest pain should go to the ER and what is likely not life-threatening and can be managed in the urgent care. I learned that the ECG is an important tool in differentiating, as well as past medical history, risk factors, and type of chest pain. Furthermore, it also taught me that many urgent care cases go into the realm of primary care as well. For example, many patients came in for COVID testing with blood pressures within the category of hypertensive urgency. If they were asymptomatic, they were told to follow-up with primary care or go to the ER based on a case-by-case basis.

For future rotations, I would like to continue to improve the skills I have learned at this rotation, until I excel at them. While the suturing in surgery is different than in urgent care, I think this will help me with the movements and just agility in general. Furthermore, I will continue to take every opportunity for blood draws, swabs, etc, so that I will be confident when I’m a PA in these situations. 

Typhon_Ambulatory Care