Question

History

 Stanley is a 19-year-old male who presents to the STD clinic because he’s had a sore

on his penis for one week.

 Last sexual exposure was three weeks prior, without a condom.

 No history of recent travel.

 Predominantly female partners (five in the last six months), and occasional male

partners (three in the 1-2 years).

 Last HIV antibody test (two months prior) was negative. Reports three children with two

different women. All children were in the province taking care of by his parents. He is

single and always on the go to mingle.

Physical Exam

 No oral, perianal, or extra-genital lesions.

 Genital exam shows an uncircumcised penis with a lesion on the ventral side near the

frenulum. Lesion is red, indurated, clean-based, and non-tender.

 Two enlarged tender right inguinal nodes, 1.5 cm x 1 cm.

 Scrotal contents are without masses or tenderness.

 No urethral discharge.

 No rashes on torso, palms, or soles. No alopecia. Neurologic exam within normal limits.

Laboratory

The results of stat laboratory tests showed the following:

 Darkfield examination of penile lesion—Positive for T. pallidum

 FTA-ABS—Reactive

 HSV culture—Negative

 Gonorrhea NAAT—Negative

 Chlamydia NAAT—Negative

 HIV antibody test—Negative

Medications

May give Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million

units IM each at 1-week intervals, but after the skin testing, Stanley shows with allergy in

penicillin so the doctor advised to take vancomycin 250 mg orally 4 times a day for 10 days

PLUS Rifampin 600 mg orally twice a day.

Partner Management

Stanley had the following sex partners during the past year:

Tracy—(met in QC Circle) Last sexual exposure three weeks ago (receptive oral and vaginal

sex with Stanley)

Richelle—(met in SM Manila) Last sexual exposure four weeks ago (vaginal sex with Stanley)

Carmina—(met in Luneta) Last sexual exposure five weeks ago (vaginal sex with Stanley)

Danielle—(met in Divisoria) Last sexual exposure six weeks ago (vaginal sex with Stanley)

Jonathan—(met in Trinoma) Last sexual exposure six month ago (receptive anal sex with

Stanley)

Tony—(met in Quiapo) Last sexual exposure eight months ago (insertive oral and anal sex

with Stanley)

Calvin—(met in Recto) Last sexual exposure ten months ago (receptive oral and anal sex with

Stanley

Follow-Up

Stan returned to the clinic for a follow-up exam one week later. Results were as follows:

 His penile lesion was almost completely healed.

 He had not experienced a Jarisch-Herxheimer reaction.

 The RPR (repeated at the follow-up visit because the initial one was negative) was 1:2.

MAKE A DISCHArge PLANNING FOR THIS CASE

Answer 1

#. Patient Teaching-General :

disorder, diagnosis, and treatment, including the need to comply with treatment

prescribed medications, such as penicillin, and the intended course of therapy depending on the stage of the disease

possible adverse effects of penicillin therapy, including headache, fever, chills, sweating, malaise, and hypotension or hypertension (Jarisch-Herxheimer reaction)

need to complete the course of therapy even after symptoms subside

importance of informing, testing, and treating sexual partners

need to refrain from sexual activity until treatment is completed and follow-up VDRL or RPR test results are normal

importance of repeat serology testing at 3, 6, 9, and 12 months after treatment and again at 24 months if the disease lasts longer than 1 year

possible need for retreatment if clinical signs persist or recur, a fourfold rise in titers occurs, or initially high titers fail to decrease fourfold by 6 months

risks to the fetus if the patient is contemplating pregnancy and the need for all pregnant patients to be screened at the first prenatal visit

information for the patient and sexual partners about human immunodeficiency virus infection

importance of safer sex practices, including the use of condoms.

#. Patient Teaching-Discharge Planning

As needed, obtain a physical or occupational therapy consultation.

Refer the patient for contact tracing.

Refer the patient to a specialist if congenital syphilis is suspected.

Consult a social worker to determine home care needs.