REASON FOR CONSULTATION: Urethritis. Please evaluate for treatment plan.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male with no significant past medical history, who is referred to us from his primary care’s office secondary to evaluation of urethritis. The patient gives a history that, about 3 weeks ago, he had unprotected sex with 3 different females. He had developed symptoms of mild dysuria, urethral discharge, and initially had thought nothing of it; however, as he developed 2 superficial blisters at the tip of his penis, he was very concerned and went to his primary care physician.
The patient was initially seen on MM/DD/YYYY. At that time, screening for STD was performed. This included Chlamydia PCR and urinalysis in addition to HIV testing. The patient also had screening for herpes simplex performed. Unfortunately, this was IgG antibody type 1 and type 2, IgM was not sent. Neisseria gonorrhoeae antibody was sent, which was noted to be less than 1:8. The patient’s Chlamydia PCR turned positive and the patient was prescribed 1 g of oral azithromycin. However, the patient gives a history that he had the blisters on the tip of his penis break down causing further irritation and mild dysuria.
At that time, he was reevaluated on MM/DD/YYYY and another course of oral azithromycin was prescribed. Again, as his symptoms did not improve, repeat course of oral azithromycin was prescribed on MM/DD/YYYY per patient. As the patient had persistence of these blisters and mild dysuria, he was referred to us for evaluation.
REVIEW OF SYSTEMS: The patient denies any fevers, chills, cough, pleuritic chest pain, orthopnea, or PND. Denies any sore throat or odynophagia. Denies headache or visual changes. Denies any urethral discharge. Gives history of mild dysuria but is particularly concerned about the blisters that are shown healing; however, are persistent. Denies any skin rashes.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: He has unremarkable surgical history.
SOCIAL HISTORY: He occasionally smokes about a half a pack a day and occasional alcohol use. No intravenous drug use is noted. He works in marketing.
FAMILY HISTORY: Unremarkable. The patient states that he has been screened for HIV in the past; however, he does not remember an accurate date and he was told he was negative.
GENERAL: On examination, he is comfortable, in no acute distress. He is awake, alert, oriented, and pleasant. He is noted to be afebrile. Heart rate is 82 and blood pressure is 156/86.
HEENT: Pupils are equal and reactive to light and accommodation. Sclerae are anicteric. Oral mucosa does not have any exudate or tonsillar enlargement.
LUNGS: Clear to auscultation.
HEART: S1 and S2 with a regular rate and rhythm.
ABDOMEN: Soft, nontender, and nondistended. Gut sounds are present. No organomegaly is palpable.
EXTREMITIES: Warm without any significant edema.
SKIN: No skin rashes are noted. No joint involvement is noted. Evaluation of his genitalia shows very superficial 2 small blisters at the tip of his penis. These have now crusted over. There is no surrounding erythema or induration. No drainage is noted. No urethral discharge is noted. No other skin lesions are identified. Mild inguinal lymphadenopathy is noted on the left side.
LABORATORY DATA: The patient had RPR performed, which was noted to be negative on MM/DD/YYYY. In addition, urinalysis was noted to be within normal limits. Serum electrolytes and liver function tests were also noted to be within normal limits. Kidney function is stable. The patient had a Chlamydia PCR done, which was noted to be negative. Gonorrhoeae antibody was noted to be negative. HIV screen was noted to be negative. Hepatitis C virus antibody was noted to be 0.1, which is negative. HSV IgG type 1 and type 2 are noted to be negative.
ASSESSMENT: This is a (XX)-year-old male, who is referred here for symptoms of urethritis. Clinical exam shows evidence of 2 small ulcerations at the tip of his penis. These were superficial ulcerations, which have now healed over and are crusted. This is ulcerative STD, therefore concerned for herpes simplex there. Syphilis is certainly in the differential; however, it appears low in probability at present. The patient indeed had Chlamydia infection, for which he was treated adequately with oral azithromycin.
The patient still has symptoms of mild dysuria. Therefore, PCR is sent for gonorrhea. However, the patient is adamant that he wants treatment; therefore, a dose of intramuscular Rocephin is arranged for the patient on the medical ambulatory floor. In addition, we would like to obtain herpes simplex IgM antibodies as the patient is concerned about the infection.
In addition, a repeat VDRL is ordered. As these lesions are completely crusted and almost healing, there is no benefit of doing PCR testing. At present, we will hold off on further treatment. The patient will be reevaluated in a week’s time. He is to call with change in status. It is important to note that the patient required screening for HIV in about 4 weeks’ time. This was related to the patient. In addition, we will repeat his urinalysis for evaluation of Trichomonas vaginalis. It is important to note that his last urinalysis was within normal limits, and Trichomonas PCR was also noted to be negative. The patient is asked to abstain from unprotected sexual intercourse for now.
