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PATIENT PRESENTATION

Chief Complaint

“I think I am allergic to something.”

History of Present Illness

JS is a 27-year-old man who presents to a free health clinic at the county hospital. He states he was in his usual state of health until about 3 days ago when he began developing a rash on his stomach that is now on the palms of his hands and soles of his feet. The rash is not painful or itchy. He states that he had this strange little “ulcer-like” thing on his penis a couple weeks ago but it went away and never really hurt. He is single and sexually active with two to three concurrent male partners. He has had unprotected sex with “at least one of his partners” in the past couple of weeks. He doesn’t know the sexual histories of his current or past sexual partners, and admits to over 15 lifetime partners. He endorses rectal and oral sex. He doesn’t ever recall being tested for HIV, and knows he received all his childhood vaccines, “cause my mom told me.” He has never been vaccinated against HPV stating, “that’s a woman’s disease,” and is unsure if he ever has received a hepatitis A vaccine.

Past Medical History

None

Surgical History

None

Family History

Father had HTN and passed away from a stroke 4 years ago; mother is still living and has type 2 DM

Social History

MSM with multiple sexual partners; (+) EtOH, (–) Tobacco, (+) Marijuana, (–) Illicit drugs

Allergies

NKDA

Home Medications

Ibuprofen 200 mg PO PRN pain (has taken 4 doses in the last day)

Physical Examination

Vital Signs

Temp 101°F, P 72, RR 16 breaths per minute, BP 141/85 mm Hg, pO2 94%, Ht 5′7″, Wt 60 kg

General

NAD, awake, alert, slightly underweight man

Skin

Diffuse mucocutaneous rash noted on abdomen, back, upper extremities (including palms of hands) and soles of feet; macules are easy to blanch and are not associated with any area of fluctuance

HEENT

PERRLA; EOMI; mucous membranes are moist and neck is supple without any evidence of lymphadenopathy

Pulmonary

Clear auscultation with no wheezing or rhonci

Cardiovascular

NSR; no m/r/g

Abdomen

NTND with no rebounding or guarding; (+) BS; noted rash as described above

Genitourinary

Abdominal rash extends to genital region ...

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