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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Discuss the diagnosis of syphilis and differentiate among the temporal stages of the disease.

  • Develop a pharmacotherapeutic treatment plan individualized for the patient’s stage of syphilis.

  • Recommend alternate treatment regimens when the primary therapeutic option is contraindicated.

  • Describe appropriate monitoring, follow-up, and counseling of patients with a syphilitic infection to ensure success of treatment.

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PATIENT PRESENTATION

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Chief Complaint

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“This rash started 3–4 days ago on my back and stomach. My whole left side has been hurting, and I’ve also been feeling weaker than usual lately.”

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HPI

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John Rutherford, a 27-year-old man with a past medical history of HIV on HAART, presents with left upper quadrant/left back/left side pain and a diffuse rash. He states the rash started 3–4 days ago, and is mostly on his chest, abdomen, and arms. He also has seven macules on his scalp. The rash is nonpainful and nonpruritic, except on his scalp where he has developed a few scabs from itching; no drainage from any lesions is noted. He also has been having some chest pain that is worse with breathing. He notes nausea, though no vomiting, and reports ongoing nonbloody diarrhea for months. He presents to the ED primarily because of pain in his upper left back that radiates around his left side. His urine is very dark, brownish-red; however, he has no dysuria. The patient also states he has felt weaker than usual for the past few days.

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PMH

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  • Hepatitis B, now immune

  • HIV diagnosed 6 months ago, on HAART

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FH

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Both parents with hypertension, still living

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SH

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  • Unemployed

  • Tobacco 1.5 ppd since early teens

  • Social alcohol usage (average four drinks per week)

  • Occasional methamphetamine use—both smoked and injected (with clean needles)

  • Previous MSM Hx (four partners in last 6 months) with inconsistent use of condoms

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Meds

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  • Tenofovir/emtricitabine 300/200 mg PO once daily

  • Raltegravir 400 mg PO BID

  • Acetaminophen–hydrocodone 325/5 mg PO Q 6 H PRN

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All

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Codeine

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ROS

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  • Constitutional: reports weakness and malaise; denies fever

  • Eyes: denies vision changes

  • Ears, nose, and throat: denies sore throat, rhinorrhea, or sinus pressure

  • Lymphatic: denies lymph node swelling

  • Respiratory: denies shortness of breath, dyspnea on exertion, or cough

  • Cardiovascular: reports some chest pain on inspiration

  • Gastrointestinal: reports intermittent nausea, no vomiting, and consistent diarrhea

  • Neurologic: denies neuropathy symptoms

  • Musculoskeletal: reports arthralgias and myalgias

  • Skin: rash on scalp, abdomen, arms, and legs present

  • Pain: reports persistent abdominal and left side pain

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Physical Examination

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Gen
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Awake and alert, NAD. Appropriate. Oriented to person, ...

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