Let’s start with a fairly short one, that addresses a common urgent care issue, as well as an important principle of medical management that they don’t teach you in med school.
STIs (aka STDs) are one of the more common issues encountered by the urgent care provider. Part of this is due to simple convenience, of course… but part of this is also embarrassment. Many people would prefer someone other than their regular primary care doctor, who may also be treating family members, know all the dark secrets of their sexual history. Also, STDs often target younger people with no primary care provider to begin with. Here is one such case.
A 26 year old African American male presented with penile discharge for 3-4 days. He says the tip was slightly irritated, with slight burning when he urinated. He did confirm unprotected intercourse with multiple female partners. He also reported some vague fatigue and stress. He had no other issues on presentation. He denied any rash or other skin lesion, fever, flank pain, nausea, vomiting, joint pain, or other issues. He said he had a cold or flu a few weeks ago but no other past medical history. He took no medications. A basic dipstick into the patient’s urine was completely normal. The physical exam was unremarkable except for some large, soft, non-tender lymph nodes in the patient’s groin. No other rashes or lesions were noted in his genital region or elsewhere. I ordered a routine STI panel and put him on empiric therapy for what I considered the most likely diagnosis.
AT THIS POINT I DID NOT KNOW THE PRIMARY DIAGNOSIS… ALTHOUGH PERHAPS I SHOULD HAVE. WHAT IS YOUR GUESS? (scroll down when ready)
Primary infection with Human Immunodeficiency Virus type 1 (HIV-1)
This is it. This is the one, the greatest and most fearsome of all the STIs: HIV, the “bug,” the “high five,” causative agent of AIDS, dark terror of the American 1980s and current scourge of Africa. Always progressive and always fatal if left untreated, AIDS is the end result if HIV is left unchecked.
Anyone who goes through med school will encounter the chronic HIV patient. For these patients, it is a lifelong thing not unlike diabetes in its day-to-day management: frequent blood tests informing the frequent medication juggling, with always plaintive and always boring preaching from the doctor about “lifestyle” and “compliance.” Many chronic HIV patients will remark that they know more about the disease than their specialist infectious-disease doctor… and they have a point. It’s frankly impossible to fully know what it’s like to have a disease unless you have it. It’s related to the old lawyer’s observation that to truly know the criminal legal system, you must have spent time in prison.
But that’s for the chronic guys. It’s pretty rare for an urgent care doc to have a new-diagnosis HIV patient, and the average doctor (including yours truly) can perhaps be forgiven for not having it in the forefront of the mind at all times.
And that brings us to the medical lesson they don’t teach you in school: the necessity of the checklist. This patient was a great example on why doctors should follow routines and checklists: to cover the things we are not actually thinking about.
For the above patient, HIV was not something I was really thinking about. I was instead going down the tried-and-true gonorrhea and/or chlamydia route given the history. What was key was sticking to a good routine, in this case: When you check for one STI, you check for them all. ALWAYS.
It only makes sense. If you’ve decided to share your genitals with someone who may have given you chlamydia, it stands to reason that this same person would be more likely than the general population to also give you a dose of syphilis. Or herpes. Or HIV.
But I wasn’t thinking about that with this particular patient, so it was nothing but my dumb, unthinking adherence to routine that picked up the diagnosis on the blood test, and saving me and the patient for the fact that I blew off the lymph nodes in his groin, or the fact that he had a “cold” a few weeks prior (which might have been caused by acute HIV infection.) It’s not just low-rank, in-the-trenches grunts like me: even highly trained surgeons or ICU specialist doctors stick to a checklist for all their new patients, because it is simply not possible to be conscious of every possible problem at all times. It’s the same with pilots or nuclear engineers, who are also intelligent and skilled specialists. They too must have a checklist or routine they can trust to serve as their professional safety net.
By the way, the patient did also have chlamydia.
In any case, a colleague was on when this patient’s bloodwork came back, positive for HIV-1 antibodies and antigens; follow-up bloodwork demonstrated a low CD4+ cell count consistent with a recent infection raging through his body. Now, the body does adapt to the HIV invasion, getting it under control and rebuilding its CD4 cells… temporarily at least. But over the course of years, through brute attrition, the virus eventually grinds the immune system and its critical CD4 cells down into the ground, leading to AIDS.
My colleague immediately referred the patient to an infectious disease doctor and contacted the health department. With proper care, HIV+ patients can lead long and productive lives, similar to the diabetes patients I mentioned earlier. It does take diligence, but HIV is no longer the dread executioner it once was. Still, there is no denying that HIV is the worst of the worst when it comes to STIs. Please insist on condoms and only condoms with a new sexual partner when one or more penises are involved, every time, no exceptions, until you know 100% sure they’re clean.