Who You Are:
You are an F2 working in GP clinic.Who the patient:
Steven McAdams, 24 years old. He has come with a skin lesion on his private parts. He is concerned about it.What you should do:
Talk to him, discuss management and address his concerns.
D: Hi I am one of the junior doctors working in this GP surgery. Can I confirm your name and age please?
P: Hello doctor my name is Steven McAdams, I am 24 years old.
D: How would you like me to call you?
P: Steven is fine doctor.
D: OK. How can I help you today?
P: Dr I feel so embarrassed (Reflect and reassure)
D: There’s no need to feel embarrassed we are here to help you. Can you please tell me what’s going on?
P: I have something on my penis. (P1)
D: Can you tell me more about that? OPEN Q the ODIPARA
P: It’s a small ulcer.
D: How did it start ? Onset
P: I’m not sure.
D: How long has it been there? Duration
P: The past 2 weeks.
D: What is the size of the ulcer?
P: Like a small coin.
D: What is the shape of the ulcer?
P: I don’t know.
D: Anything else with the ulcer?
P: Yes I also have a rash.
D: What is the colour of the rash?
P: Red.
D: Any recent change in colour, shape, size?
P: Not sure.
D: Is there any discharge from the rash?
P: No.
D: Is the ulcer itchy?
P: No.
D: Is it painful?
P: No.
D: Any other skin lesions in the body?
P: No.
FLAWS
D: Any fever or flu-like illness recently?
P: No.
D: Any lumps or bumps in the body?
P: Yes, I have some around my groin for almost 2 weeks now .
D: Does those hurt?
P: No.
D: Any tiredness? ( HIV )
P: No.
D: Any weight loss? ( CANCER )
P: No.
D: Any loss of appetite?
P: No.
D: Any headache? (Neuro syphilis )
P: No.
D: Any rashes anywhere else in the body? (Generalized syphilis)
D: Any weakness in any part of the body? (Neuro/meningosyphilis)?
D: Any long-term exposure under the sun or skin tanning sessions?
P: No.
D: Any joint pain?
P: No.
D: Any rash on the palms or soles?
P: No.
D: Any white patches in your mouth? (Immunocompromised)
P: No.
P2+ MAFTOSA
D: Have you been exposed to someone having similar skin lesions? CONTACT
IMPORTANT
P: No.
D: Have you had a similar health condition in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Are you currently on any medication?
P: No.
D: Are you allergic to any foods or medication?
P: No.
D: Any family history of any significant health issues or skin problems?
P: No.
DESA
D: Do you smoke?
P: Yes ( what do you smoke , how many , for how much time )
D: Do you drink Alcohol?
P: No.
D: Tell me about your diet?
P: I have a balanced diet.
Sexual history VERY IMPORTANT
D: Are you currently sexually active?
P: Yes.
D: Are you in a stable relationship?
P: No, I have multiple partners.
D: May I ask about your sexual orientation?
P: I am a gay.
D: Do you use condoms?
P: No I don’t use any condoms to be honest.
D: Preferred route of sex
P: anal and oral .
D: Any pain during or after sex?
P: No
EXAMINATION:
If you don’t mind, I would like to do a GPE, check your BP, temperature, RR. Pulse rate and examine the ulcer.
MANAGEMENT
EXPLAIN CONDITION
From what you have told me and from what I have assessed (mention positive findings), I suspect you have syphilis. Do you have any idea what syphilis is? (Idea) Syphilis is a bacterial infection that’s usually caught by having sex with someone who’s infected.
D; Do you have any concerns so far? Concerns
P: How are you going to treat me?
Management
Senior:
Investigations:
We will be doing further investigation, like some routine bloods and some antibody tests (treponema serology test) in GP practice to confirm the diagnosis. We will refer you to the GUM clinic. They might take a swab from the lesion and some more blood samples.
Treatment:
- Injection of antibiotics (For syphilis lasting more than 2 years) into your buttocks most people will only need 1 dose of Penicillin, although 3 injections given at weekly intervals may be recommended if you have had syphilis for a long time.
- Course of antibiotics tablets if you cannot have the injection - this will usually
last 2 or 4 weeks, depending on how long you have had syphilis
Lifestyle Advice:
- Avoid any kind of sexual activity until at least 2 weeks after treatment finishes.
- It is very important to bring in your partners and so we can treat them as well if they have got the infection.
- If you are not able to bring your partners, we can contact them through our
anonymous partner notification program.
D: We usually offer a HIV test to those who have any kind of sexually transmitted
infections. Do you wish to have one?
P: No.
If the patient stops talking, ask about any other concerns.
P: Can I get it again? (concern)
D: You can catch syphilis more than once, even if you have been treated for it before.
P: How can I prevent syphilis? (concern)
D: Syphilis cannot always be prevented, but if you’re sexually active you can reduce your risk by:
− practicing safe sex: male condom or female condom during vaginal, oral and
anal sex.
− use a dental dam (a square of plastic) during oral sex
− avoid sharing sex toys – if you do share them, wash them, and cover them with a condom before each use.
− If you inject yourself with drugs, avoid sharing needles with others. Be aware of
needle exchange program.
Safety net:
If you develop any of the following please come back to the GP again:
− sore throat
− white patches in the mouth
− any tingling or numbness in your hands or feet
− any vision problems please come back to us.Leaflets
− Specific expectations
Follow up
We will have further follow-up appointments to make sure that you’re responding well
to treatment. Wish you a speedy recovery.
MORE INFORMATION
- The symptoms of syphilis are not always obvious and may eventually disappear, however the person will always be infected unless treated properly.
- Syphilis may have no symptoms or can include:
− small, painless sores or ulcers or small skin growths (similar to genital warts)
affecting genital organs (penis, vagina, vulva, or around the anus), blotchy red
rash on the palms and soles.
− white patches or ulcers in the mouth.
− tiredness, headaches, joint pains, a high temperature (fever) and swollen glands
in your neck, groin or armpits. - If left untreated can spread to the brain or other parts of the body and cause serious long-term problems.
- How syphilis is spread: Syphilis is mainly spread through close contact with an infected sore.
− Vaginal, anal or oral sex.
− Sharing sex toys with someone.
− Sharing needles.
− Blood transfusions, but this is very rare in the UK as all blood donations are tested for syphilis.
− Pregnant women with syphilis can pass the infection to their unborn baby.
Syphilis cannot be spread by using the same toilet, clothing, cutlery, or bathroom with
an infected person.
Syphilis in pregnancy
It can be very dangerous for the baby if not treated as it can lead to miscarriage, stillbirth or a serious infection in the baby (congenital syphilis). Screening for syphilis during pregnancy is offered to all pregnant women so the infection can be detected and treated before it causes any serious problems.
Complications of syphilis: Meningitis, Stroke, Dementia, Heart diseases. Syphilis is divided into stages (primary, secondary, latent, and tertiary), with different signs and symptoms associated with each stage. A person with primary syphilis generally has a sore or sores at the original site of infection.