Full Name: L.N

Date of Birth: 08/1/1995

Location: SSFM

Source of Information: Self

Reliability of patient: Reliable

Source of Referral: Self

Mode of Transport: Self

 

Chief Complaint: “I recently had a herpes outbreak, and I want to know if I can have sex with my partner without giving it to her” x 10 days

 

History Of Present Illness: 27 y/o M with PMH of HSV2 ℅ recent herpes outbreak on his pubic area ten days ago. Pt notes he had 3-4 small lesions with a moderate amount of clear discharge. Pt notes pain was 3/10 over the past ten days but notes he does not have any pain now. Pt has been taking Valtrex (Valcyclovir) 1g q12 hrs since the lesions appeared. Pt notes the lesions are “almost healed” but have resulted in 3-4 dark scars around his pubic area and would like to ensure he is safe before resuming sexual activity with his girlfriend. Pt notes this is his 2nd outbreak since he was diagnosed in 2018. Pt denies cough, dysuria, urinary frequency/urgency, penile discharge, penile pain, or hx of any other STIs.

 

PMH: HSV2 – dx five years ago

 

Past Surgical History: None

 

Allergies: None

 

Medications: Valtrex (valacyclovir): 1g PO q12 hrs – HSV2

 

Family History:

Grandparents: Pt does not recall the age or cause of death

Mother – 56, alive and well, no significant PMH

Father –  58, alive and well, no significant PMH

Brother – 24, alive and well

 

Social History: L.N is a 27 y/o male who has 1 mixed drink per week when out with friends. Pt notes he uses marijuana every day (1 blunt). Pt denies the use of tobacco products or other illicit drugs. Pt is currently active with one partner and uses condoms. 

 

Review of Systems:

 

General – Denies fever, chills, night sweats, loss of appetite, weight loss/gain, or weakness/fatigue.

 

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, pigmentations, moles/rashes, pruritus or changes in hair distribution.

 

Head:  Denies vertigo or head trauma.

 

Eyes: Denies using reading glasses, visual disturbances, photophobia, lacrimation, or pruritus.

 

Ears – Denies deafness, pain, discharge, tinnitus, or use of hearing aids.

 

Mouth/throat: – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use of dentures.

 

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion.

 

Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND)

 

Cardiovascular system – Denies chest pain, hypertension, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, or heart murmur.

 

Gastrointestinal system – Has regular bowel movements daily. Denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructation, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in the stool.

 

GU – See HPI

 

Nervous – Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status/memory, or weakness.

 

Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE.

 

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

 

Psychiatric – Denies depression/sadness, anxiety, OCD, or ever seeing a mental health professional.

 

Physical

 

BP: 128/72

 

Pulse: 72

 

Temp: N/A

 

Ht: 5’11

 

Weight: 160

 

BMI: 22.3

 

SpO2: N/A

 

General: Pt appears mildly anxious but does not appear to be in acute distress. Appears stated weight and age, neatly groomed

 

Skin: warm & moist, good turgor. Nonicteric, no lesions noted, no scars, no tattoos.

 

Eyes: Pupils are symmetrical and equal round and reactive to light. 

 

Ears: Symmetrical and appropriate in size. No lesions/masses/trauma on external ears. No discharge / foreign bodies in external auditory canals AU.

 

Nose: Symmetrical / no masses / lesions / deformities / trauma / discharge. Nares patent bilaterally / Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions / deformities / injection / perforation. No foreign bodies.

Sinuses: Non tender  frontal, and maxillary sinus palpation.

Lips: Pink, moist; no cyanosis or lesions.

Mucosa: Pink; well hydrated. No masses; no lesions noted.

Palate: well hydrated.  Palate intact with no lesions; masses; scars.

Teeth: Good dentition. No dentures, no other dental caries noted.

Tongue: Pink; no masses, lesions or deviation.

Oropharynx: Well hydrated; no injection; exudate; masses; lesions; foreign bodies. Tonsils present with no injection or exudate. Uvula pink, no uvula deviation, no edema, lesions

Neck: Trachea midline.  No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation.

Thyroid: Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Chest: Respirations unlabored / no paradoxical respirations or use of accessory muscles noted. 

Lungs: Clear to auscultation and percussion bilaterally. No adventitious sounds noted and symmetrical rise and fall of the chest bilaterally.

Heart: Regular rate and rhythm with normal S1 and S2 sounds. No JVD, murmurs, S3, S4, or splitting of heart sounds, or friction rubs. Carotid pulses are 2+ bilaterally without bruits.

Abdomen: Abdomen flat and symmetric with no scars, striae, or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation and tympanic throughout; no guarding or rebound noted. No hepatosplenomegaly to palpation, no CVA tenderness appreciated.

GU: three 3cm dark scars diffuse surrounding pubic area. No penile or scrotal rash, lesions, mass, or discharge noted.

Differential diagnosis: 

HSV 2 Outbreak: Pt has hx of HSV 2 and reports this was similar to his last outbreak. Patient’s history and exam findings correlate with resolving/resolved HSV lesions. 

Miliaria: Patient has small resolving dark spots in pubic area, and the weather has been very hot and humid (85 – 90 degrees F). This is unlikely due to the heat rash being localized to one area, and is this area is usually covered well.

HPV infection: Most common STI in the US. Unlikely because HPV lesions are flesh-colored but are more like cauliflower projections and painless.

Assessment & Plan:

L.N is a 27 y/o M with PMH of HSV2 presenting with a resolving Herpes 2 outbreak. 

 

Plan:

Counseling: Continue taking Valtrex for at least 1-3 more days, depending on symptoms. As long as lesions do not have discharge and are not open, the patient should be able to have sex with his partner without transmitting the disease. Pt is advised to wear a condom still to prevent possible spread of infection or contracting other infections. Advise the patient to return if symptoms worsen or reappear. If symptoms reoccur, the patient may need Acyclovir 400mg PO every 8 hours for five days. 

 

https://www.ncbi.nlm.nih.gov/books/NBK554427/

https://my.clevelandclinic.org/health/diseases/21136-cold-sores

 

PDF: H&P Family Med #2