Health Assessment

Syphilis

Colleen Burgoyne, DNP, RN, FNP-BC

Case Study

Chief Complaint

“I think I might have the flu, and I have a rash.”

Patient Profile

Name: Kevin O’Brien

Age: 22 years old

Gender: male

History of Present Illness

Mr. O’Brien is a 22-year-old man accompanied by his mother for today’s appointment.

Kevin reports that for the past week, he has been feeling poorly with fevers up to 101.3°F, myalgias, headaches, and sore throat. He also reports a rash over his whole trunk and that he has noticed hair loss.

He denies any nausea, vomiting, or diarrhea, though he reports that his appetite is poor. He denies any cough, shortness of breath or chest pain.

He denies any recent travel and is not aware of any sick contacts.

Allergies

Penicillin: His reaction is a rash. This occurred when he was 4 years old and was prescribed amoxicillin for an ear infection. He did not require any treatment or emergency care for the rash. He has never taken penicillin-type antibiotics since then.

Medical History

  • ADHD
  • Asthma

Medications

Albuterol MDI: 90 mcg as needed for wheezing

Dextroamphetamine-amphetamine: 20 mg ER, 1 capsule every 24 hours

Social History

  • Intern with law office.
  • Smoking: Never smoked.
  • Alcohol use: Reports that he drinks alcohol about once/week, but consumes 3-4 drinks on each occasion.
  • Cannabis: Smokes marijuana using a vape pen daily.
  • Consumes THC gummies, 2-3 times/week.
  • Illicit substances: Denies ever using intravenous drugs. He reports occasional intranasal cocaine use, usually 2-3 times/month. He also occasionally uses 3,4-methylenedioxymethamphetamine, which he refers to as “Molly.”
  • Family/living situation: He graduated from college a few months ago. Since graduating he has been staying in the carriage house on his parent’s property.
  • Occupation: Working part-time as an intern in his father’s law firm. He is applying to law school and plans to attend at the start of the next academic year.
  • He has remained active by playing in the soccer league at his parents’ sports club. He has also recently started playing tennis again.

Family History

  • Father: hyperlipidemia, hypertension
  • Mother: fibromyalgia
  • Brother (older): deceased at age 30 due to melanoma
  • Maternal grandmother: deceased at age 78 due to breast cancer
  • Maternal grandfather: deceased at age 75 due to myocardial infarction

Review of Systems

  • General: Denies weight gain or loss. Reports fevers, chills, and fatigue as per HPI.
  • Skin: Reports rash over the chest, back, and abdomen for the past several days.
  • HEENT:
    • Head: Denies trauma. Reports intermittent headaches for past 7 days.
    • Eyes: Denies pain, double vision, blurred vision, excessive teary, drainage, and changes in visual acuity.
    • Ears: Denies changes in hearing acuity, tinnitus, vertigo, pain, and drainage.
    • Nose: Denies nasal drainage, epistaxis, and sinus pain.
    • Mouth and throat: Denies throat pain, difficulty swallowing, and hoarse voice. Denies any active tooth pain. He sees a dentist regularly. Last visit was 2 months ago.
  • Neck: Denies pain, stiffness. Reports some enlarged lymph nodes.
  • Respiratory: Denies cough, shortness of breath, hemoptysis, and chest pain.
  • Cardiovascular: Denies chest pain, palpitations, shortness of breath, and swelling in the extremities.
  • Gastrointestinal: Denies nausea, vomiting, diarrhea, abdominal pain, constipation, bloody or black tarry stools.
  • Peripheral Vascular: Denies leg pain, varicose veins, swelling in the extremities, and changes in temperature or color of the extremities.
  • Urinary: Denies dysuria, hematuria, frequency of urination, urgency of urination, incontinence and suprapubic pain.
  • Genital: Denies discharge from the penis, scrotal pain, or swelling. Reports that he did have an open sore near the base of his penis about 4-6 weeks ago, but it resolved quickly.
  • Musculoskeletal: Reports pain in the right elbow which has been present for 2-3 months. The pain limits his range of motion of the right elbow joint. He denies any redness or swelling of the right elbow and does not recall any injury or trauma to the area. Denies any joint redness, pain, or swelling in any other joint. Denies back pain.
  • Psychiatric: Denies feeling depressed or anxious. Denies memory changes, hallucinations. Denies suicidal and homicidal ideation.
  • Neurological: Denies confusion, syncope, numbness in any extremity, weakness in any extremity, tremors, or seizures. Reports headache.
  • Hematologic: Denies easy bruising or bleeding.
  • Endocrine: Denies heat or cold intolerance, excessive sweating, excessive thirst, excessive hunger, or increased urine output.

Activity: Differential Diagnoses

  1. You are starting to formulate differential diagnoses based on the history obtained so far. What additional history elements are most important to obtain?
    1. Sexual history
    2. 24-hour food recall
    3. Detailed psychiatric history
    4. Dental history
  1. The patient’s mother is present during the appointment. She is very anxious about his illness and has been answering most of your questions about history so far. What is the best approach to obtaining an accurate and complete sexual history in this situation?
    1. The patient chose to bring his mother to the appointment. This demonstrates that he is comfortable addressing these issues in her presence, so you proceed with the sexual history questions.
    2. Ask the patient if he has anything else that he would like to share with you. This gives him an opportunity to bring up any concerns related to sexual health or to disclose any high-risk sexual behaviors.
    3. Inform the patient and the mother that you will now need to discuss some more sensitive topics. Offer to escort the mother back to the waiting room and inform her that you will invite her to return for the conclusion of the appointment.
    4. Ask the patient to send you a patient portal message after the appointment with a full accounting of his sexual practices over the past year. This will save time and avoid the discomfort of discussing sexual behavior in front of his mother.

Case Study Continued

Sexual History

After you escort Kevin’s mother back to the waiting room, you obtain a sexual history. A framework of topics and questions along with Kevin’s responses is available in Table 1.

Table 1. Sexual History
Sexual History Component
 Questions Mr. O’Brien’s Responses
Partners
 When was the last time you had intimate physical contact with someone? One week ago
Did that contact include sexual intercourse? Yes
What are the genders of your sexual partners? Mostly female but I did have one male partner.
How many sexual partners have you had in the last 6 months? In the last 5 years? In your lifetime? 4 partners in the last 6 months. 9 in the last 5 years. 9 lifetime partners.
Have you had any new partners in the last 6 months? Yes, 2 new partners in the past 6 months. One was a male and one is his current partner who is female.
Practices
 What kinds of sex do you have? Mostly vaginal and oral sex lately.  He reports that he has had insertive anal sex on several occasions in the past. The most recent occasion was about 3-4 months ago with a male partner.

 
Protection from STIs What do you do to protect yourself from HIV and STIs? He does not use condoms with his current partner. He explains that this is because they have been together in a committed relationship for about 4 months now. His condom use prior to this has been sporadic.
Past History of STIs
 Have you ever had a sexually transmitted infection such as gonorrhea, chlamydia, herpes, genital warts, syphilis or HIV? No
Have you ever been tested for STIs? If so, when was the latest testing done? Yes, most recent testing was 6 months ago.
Pregnancy Plans Do you have any plans to have children? Someday in the future but not currently.
Are you doing anything to prevent pregnancy? Yes. He states that his partner takes an oral contraceptive.
Are you concerned about getting your partner pregnant? Yes. Mr. O’Brien becomes anxious with this question. He is concerned that his partner is pregnant. She has shared with him that she has been inconsistent in taking her oral contraceptive and she has not started her menstrual period which was expected nearly 2 weeks ago.

Physical Assessment

Vitals

  • Heart rate: 90 bpm
  • Respiratory rate: 16 bpm
  • Blood pressure: 102/64 mm Hg
  • Oxygen saturation: 98% on room air
  • Temperature: 97.9°F
  • Height: 6 ft 1 in (185.4 cm)
  • Weight: 170 lbs
  • BMI: 21.1

General Survey

  • General appearance: Ill-appearing young man. He appears well-groomed and is dressed in clean-appearing lounge clothes which are appropriate for the weather.
  • HEENT:
    • Head: Head is normocephalic/atraumatic. Scalp is without lesions. Hair is of normal texture, but distribution shows areas of patchy alopecia in a moth-eaten pattern without scarring.
    • Eyes: Pupils 3 mm constricting to 2 mm with exposure to light, round, regular bilaterally. Sclera are white bilaterally. No conjunctival injection. Optic disc margins are sharp bilaterally. No arteriolar narrowing or AV nicking bilaterally.
    • Ears: Tympanic membrane in the left ear is intact with a visible cone of light. The right TM is partially obscured by a moderate amount of amber-colored cerumen Hearing acuity is good with whispered voice test. No tenderness with palpation of the external ear structures.
    • Nose: Mucosa are pink, septum is midline. No sinus tenderness.
    • Oral: Dentition appears to be in good repair with no obvious areas of decay or broken teeth. Gingival tissue is pink and without swelling. Tongue is midline. Pharynx is without exudate. There are two lesions of white/gray patches on the dorsal surface of the tongue which are about 1-2 cm in diameter and have a verrucous surface.
  • Neck: Supple, trachea is midline. Full active range of motion with flexion, extension, tilt bilaterally and rotation bilaterally. Submandibular and anterior cervical lymph nodes are enlarged bilaterally, about 1-2 cm, rubbery and mobile, non-tender.
  • Respiratory: Respiratory rate is normal and breathing appears unlabored with no use of accessory muscles. Thorax expansion is symmetric. Lung sounds are clear to auscultation in 3 lobes on the right and 2 lobes on the left.
  • Cardiovascular: S1/S2 with S3 during diastole and heard best at the apex of the heart. No murmur or rub. No edema in extremities bilaterally.
  • Abdomen: Flat, soft, non-tender, bowel sounds active in all quadrants. No masses. No pain with palpation. Liver span is 7 cm at the right midclavicular line, liver edge is smooth and palpable 1 cm below the right costal margin. The spleen is not palpable. Negative CVA tenderness bilaterally.
  • Musculoskeletal: No erythematous, edematous, or deformed joints on inspection. No spinal tenderness with palpation. He has tenderness with palpation of the right elbow, just lateral and distal to the medial epicondyle, the pain is worse with flexion of the wrist against resistance. Range of motion with extension of the right elbow is slightly limited.
  • Neurological: Alert and cooperative. Oriented to person, place, time, and situation. Cranial nerves II-XII intact. 5/5 strength in bilateral upper and lower extremities.
  • Skin: There is a diffuse, symmetrical pattern of numerous macules on the anterior and posterior of the trunk. The macules measure about 0.5-2 cm in diameter, copper-colored and have a slightly scaly surface. There are several similar lesions on the palms of the hands and the soles of the feet bilaterally.
The palmar view of a patient’s hand showing several scattered, circular, hyperpigmented lesions.
Figure 1. Keratotic lesions on the palmar aspect of the hand of a patient with secondary syphilis
Anterior view of the torso and upper arms of a male patient with a pigmented macular rash
Figure 2. A pigmented macular rash with signs of scaling is seen across the torso and upper arms of this male patient. This rash is a manifestation of secondary syphilis.

Laboratory Results

Kevin has lab results from 8 months ago from an evaluation for sexually transmitted infections. These results are negative for gonorrhea, chlamydia, syphilis and HIV.

Activity: Differential Diagnoses

Select the three diagnoses which should be included in the differential for this patient:

  • HIV
  • Fibromyalgia
  • Syphilis
  • Contact dermatitis
  • Meningitis
  • COVID-19
  • Fungemia
  • Lymphoma

You decide to collect blood samples to test for syphilis and HIV.

The recommended screening test for HIV is a fourth-generation combined antigen/antibody immunoassay with a confirmatory antibody-only HIV-1/HIV-2 differentiation immunoassay (Sax, 2024). Though not used for routine screening, in this case, because Mr. O’Brien has a clinical presentation that is consistent with possible acute HIV infection, it is crucial that a PCR-based HIV viral load test is performed as well. The reason for this additional test is that in early HIV infection, production of specific antibodies may not have occurred, which would potentially result in a negative test result on the antigen/antibody immunoassay test despite acute infection (Sax, 2024).

Syphilis is diagnosed using serological testing, which detects humoral immune response to Treponema pallidum, the causative organism of syphilis. Evaluating for syphilis requires treponemal and non-treponemal serological testing. Treponemal tests assess for antibodies to T. pallidum. Non-treponemal tests use antigen detection to assess for serum which has reacted to T. pallidum and for antigens found in the cell membrane of T. pallidum (Papp et al., 2024). Syphilis testing must include both treponemal methods and non-treponemal methods in order to distinguish untreated infection from a history of successfully treated syphilis (Papp et al., 2024).

Mr. O’Brien’s results for HIV and syphilis testing are below.

Table 2. Laboratory Results for Kevin O’Brien
Test Kevin O’Brien’s Result
HIV antigen/antibody Not detected
HIV viral load Not detected
Syphilis screen (test method: CMIA) Positive
Syphilis Status Reactive
Syphilis confirmatory testing (method: TPPA, gelatin particle agglutination) Positive
RPR screen Positive
RPR titer (charcoal particle agglutination) 128

HIV, human immunodeficiency virus; CMIA, chemiluminescent magnetic microparticle immunoassay; TPPA, treponema pallidum particle agglutination; RPR, rapid plasma reagin

The interpretation of the results above is that Mr. O’Brien has syphilis infection but does not have HIV infection. Based on his presentation and these laboratory results, you diagnose him with syphilis. However, you are not done. It is important to synthesize the findings of your history and physical exam in the context of the laboratory results to determine the stage of his syphilis infection. This is an essential step because the treatment for syphilis infection is based on the stage of the infection. The sexual history is also helpful in understanding the staging of the infection. Kevin reported an instance of unprotected insertive anal sexual intercourse with a male partner about 3-4 months prior. In the United States, there has been an increase in rates of primary and secondary syphilis cases particularly in men who have sex with men (MSM) (Hicks & Clement, 2023).

To prepare for staging Mr. O’Brien’s syphilis infection, go back to the case and review the history and physical exam findings. Then answer questions 4 and 5.

Checkpoint

From the list below, select all of Mr. O’Brien’s physical exam findings which are clinical manifestations of syphilis

  1. Heart rate = 90 bpm
  2. Moth-eaten pattern of alopecia
  3. Sharp optic disc margins
  4. Excessive production of amber-colored cerumen in the right ear
  5. White/gray lesions on the tongue
  6. Cervical lymphadenopathy
  7. S3 heart sound
  8. Liver span of 7 cm
  9. Non-palpable spleen
  10. Tenderness with palpation of the right elbow, just lateral and distal to the medial epicondyle
  11. A diffuse, symmetrical pattern of numerous macules on the anterior and posterior of the trunk
  12. Non-tender epididymis
  13. Inguinal lymphadenopathy

Syphilis Diagnosis & Stages

Syphilis is an infection with the spirochete bacteria, treponema pallidum. The course of syphilis is divided into primary, secondary, and tertiary stages (see Table).

Table 3. Syphilis Stages & Presentation
Syphilis Stage Clinical Presentation
Early
 Primary A painless chancre at the site of inoculation develops ~ 3 weeks after exposure

Typically, no systemic symptoms are present during this stage.

Even without treatment, the chancre will completely heal within 2 – 6 weeks
Secondary ~2 months after the primary infection

Approximately 25% of individuals with untreated infection develop a systemic illness

Acute manifestations of secondary syphilis typically resolve spontaneously, even in the absence of therapy
Early latent Asymptomatic infection that was acquired within the previous 12 months
Late
 Tertiary Cardiovascular syphilis Untreated during the earlier stages of syphilis

Affects the ascending thoracic aorta resulting in a dilated aorta and aortic valve regurgitation

Insidious onset

Asymptomatic murmur or with left heart failure

Manifestations present 15 to 30 years from initial infection in the untreated patient.
Gummatous syphilis Gummas: ulcers or  granulomatous lesions with a round, irregular, or serpiginous shape
Late Neurosyphilis General Paresis Usually develops 10 to 25 years after infection. In early stages

Forgetfulness and personality changes are early symptoms

Patients then experience progression in memory and judgement deficits leading to severe dementia.

Some patients develop significant psychiatric symptoms including mania and psychosis
Tabes Dorsalis Disease of the posterior columns of the spinal cord and the dorsal roots.

Onset is approximately 20 years after initial infection

Sensory ataxia and lancinating pains are the most common symptoms

Pupillary irregularities are a common physical exam finding
Late latent Asymptomatic infection that was acquired within the previous 12 months
Variable
 Ocular syphilis & otosyphilis Ocular syphilis and otosyphilis can occur at any stage of infection, but are most common during the early stages

Ocular syphilis is more common that otosyphilis

Activity: Syphilis Stages

Based on Table 3 and Mr. O’Brien’s presentation, what is the stage of his syphilis infection?

  1. Primary
  2. Secondary
  3. Tertiary
You have diagnosed Mr. O’Brien with secondary syphilis. According to treatment guidelines, he should be treated with a single dose of 2.4 million units of benzathine penicillin intramuscularly. The treatment guidelines specify that penicillin-allergic patients can receive an alternative regimen of doxycycline 100 mg twice daily by mouth for 14 days.

Activity: Syphilis Treatment

How will you proceed with treating secondary syphilis for Mr. O’Brien?

  1. He has a documented penicillin allergy. Therefore, he should be treated with the alternative regimen of doxycycline.
  2. The risk that a patient with penicillin allergy will also have a reaction to doxycycline is significant. Therefore, he should be treated with the second alternative of azithromycin.
  3. His penicillin allergy does not appear to be an Ig-E mediated reaction and occurred > 10 years ago. He should undergo further evaluation of the allergy to ascertain if his penicillin allergy can be de-labeled.
  4. It is unlikely that his penicillin allergy is serious.  Since penicillin is the first line treatment, you prescribe this but also provide a prescription for doxycycline with instructions for him to switch from penicillin to doxycycline in the event of an allergic reaction.

Review Questions

Click the arrow to expand the section and view the correct answers.

  1. Mr. O’Brien asks about his girlfriend’s risk of being infected with syphilis. What is the appropriate response?
    1. Her risk is minimal given that she and Mr. O’Brien have not had intercourse since he became ill.
    2. She has some risk of having acquired syphilis. She should be counseled to monitor closely for any signs or symptoms. If signs and symptoms of syphilis develop, then she should be tested and treated according to the results.
    3. She should be clinically evaluated for signs or symptoms of syphilis and serologic testing should be done. However, she needs to be empirically treated for syphilis regardless of the results of those assessments.
    4. She is presumed to be infected with syphilis because she has had sexual intercourse with an infected person (Kevin) and will need to be treated. There is no need to pursue testing since she is presumed to be infected by epidemiology. Treatment can be prescribed without a clinical evaluation by using expedited partner therapy.
Answer:

C. She should be clinically evaluated for signs or symptoms of syphilis and serologic testing should be done. However, she needs to be empirically treated for syphilis regardless of the results of those assessments.

Feedback: Choice “A” is incorrect because although she has not had intercourse with Kevin since he has been ill, he likely acquired the infection 3-4 months ago and had evidence of primary syphilis about 6 weeks ago when he had a genital chancre, which was minimally symptomatic. Therefore, she has been exposed to syphilis.

Choice “B” is incorrect because, as detailed in the sexual history, she has had sexual contact with Kevin within 90 days of the diagnosis being made. With this being the case, there is a possibility that she has acquired the infection very recently and serological testing may be negative very early in infection. Presumptive treatment, even if serological testing is negative, is recommended for people who have had sexual contact with a person diagnosed with primary, secondary or early latent syphilis < 90 days before the diagnosis is made (CDC, 2024).

Even though she will be treated presumptively regardless of serological testing or lack of symptoms, it is still important that the girlfriend be clinically evaluated and have the serological testing performed. She needs to be evaluated for signs or symptoms of neurosyphilis, otosyphilis, or ocular syphilis, which would require treatment with intravenous penicillin. Collection of syphilis serology is also important because it allows response to treatment to be monitored via the magnitude of the decrease in the rapid plasma reagin (RPR) titer.

Expedited partner therapy (EPT) is the practice of treating the sex partners of a patient diagnosed with a sexually transmitted infection (STI) without a professional clinical evaluation or relationship with the prescribing clinician. In New York state, EPT is permissible for treatment of people exposed to chlamydia, gonorrhea, and trichomoniasis. It cannot be used to treat syphilis (New York State Department of Health, 2022).

Syphilis During Pregnancy

The evaluation and treatment of Kevin’s partner is particularly important given his concerns that she may be pregnant. Treponema pallidum is transmitted from mother to fetus in utero resulting in congenital syphilis. Congenital syphilis is a preventable infection which can have potentially serious consequences for the infant. Additionally, syphilis infection during pregnancy is associated with adverse outcomes including fetal loss, stillbirth, prematurity, neonatal death, and low birth weight (Arrieta, 2025).

In an effort to reduce rates of congenital syphilis, New York State law requires that pregnant people be screened for syphilis at least three times during each pregnancy: (1) at the time of first examination, (2) during the third trimester, and (3) at delivery (New York State Department of Health, 2025).

  1. Mr. O’Brien described several sexual practices which put him at increased risk for acquiring HIV (human immunodeficiency virus). Which of the following is the correct course of action for the nurse practitioner to take in response to identifying this risk?
    1. Refer him to a psychologist for counseling services, so that he can work through the psychological issues which cause him to engage in this kind of sexual behavior.
    2. Require him to sign a behavioral contract with your practice, stating that he will no longer engage in high-risk sexual practices.
    3. Discuss pre-exposure prophylaxis (PrEP) with the patient as a method of reducing his risk of acquiring HIV infection.
    4. Inform him that you are required to notify his employer of his sexual practices.
Answer:

C. Discuss pre-exposure prophylaxis (PrEP) with the patient as a method of reducing his risk of acquiring HIV infection.

Feedback: Pre-exposure prophylaxis (PrEP) is an effective strategy for HIV prevention. The efficacy of PrEP in reducing HIV transmission has been demonstrated in several patient groups: (1) men who have sex with men (MSM) and transgender women who report sexual behaviors associated with HIV infection, such as anal sex without barrier protection, (2) heterosexually active persons who have sex with partners who are at high risk of HIV infection, and (3) persons who inject drugs. PrEP is recommended for patients who are at highest risk of acquiring HIV through sexual activity (Table 4) (Krakower & Mayer, 2025).

Table 4. Groups at Increased Risk for Acquiring HIV based on sexual risk
Highest risk of HIV transmission High risk of HIV transmission Lower risk of HIV transmission
Anal sex (insertive or receptive) Condomless sex with partner with HIV, whose viral load is >200 copies/mL or is unknown

Condomless sex with multiple or anonymous sex partners, particularly male same-sex intercourse

Condomless sex with a main partner at high risk for HIV (e.g. partner has condomless anal sex with multiple partners or shares needles when injecting drugs)

Has been diagnosed with an STI

 Other types of condomless anal sex (e.g. multiple heterosexual partners without known risk factors for HIV)
Vaginal sex (insertive or receptive) Condomless sex with a partner with HIV and the viral load is >200 copies/mL or unknown

Condomless sex with multiple/anonymous partners from regions with high prevalence of HIV

 Condomless sex with partner(s) at high risk for HIV in low prevalence regions

Has been diagnosed with syphilis, gonorrhea, mpox

 Condomless sex with multiple partners from regions with low HIV prevalence if the partners are not known to be at increased risk for HIV

Has been diagnosed with chlamydia or trichomonas

Adapted from Krakower & Mayer (2025).

  1. Which of the following statements regarding confidentiality and syphilis is correct?
    1. Syphilis is a reportable communicable disease; therefore the local health department must be notified of the case. This responsibility is shared amongst physicians, nurse practitioners, nurses, healthcare facilities, and laboratories.
    2. Information related to sexually transmitted infection is protected by even more stringent laws and regulations than other health information. As a result, the diagnosis cannot be reported to local health authorities without the patient’s consent.
    3. The nurse practitioner is responsible for notifying all sexual contacts of the patient of his diagnosis.
    4. The laboratory is fully responsible for reporting positive syphilis results to the local health authorities.
Answer:

A. Syphilis is a reportable communicable disease; therefore the local health department must be notified of the case. This responsibility is shared amongst physicians, nurse practitioners, nurses, healthcare facilities, and laboratories.

Feedback: Syphilis is a communicable disease which must be reported to local health authorities. This responsibility is shared between healthcare providers and the laboratory processing the samples. Part of the reason for this being a shared responsibility is that probable cases must be reported, in addition to confirmed cases. The laboratory will not have the clinical information needed to determine the diagnosis and the stage of infection.

Clinical Pearls

  • Whom to test for syphilis
    • Patients with signs or symptoms of infection
      • Painless genital ulcer
      • Diffuse, symmetric macular or papular eruption involving the entire trunk and extremities
      • Any sexually active patient with an undiagnosed genital ulcer or a rash that involves the palms and soles
      • General paresis
      • Tabes dorsalis
      • Signs and symptoms that are less specific for syphilis, if no other likely etiology is identified
        • Cranial nerve dysfunction
        • Chronic headache
        • Aortic insufficiency
        • Meningitis
        • Other meningovascular disease, including cerebrovascular accidents
    • Asymptomatic patients who are at high risk of acquiring or transmitting the infection
      • Pregnant women-regardless of perceived risk
      • Patients with a sexual partner who has early syphilis (ie, primary, secondary, or early latent) syphilis
      • These patients should receive empiric therapy as well
      • Sexually active men who have sex with men
      • People living with HIV
      • People receiving pre-exposure prophylaxis (PrEP)
      • People currently engaging in high-risk sexual behaviors
        • Diagnosed with a sexually transmitted disease
        • Exchange of sex for drugs or money
        • Condomless sex with multiple partners
      • Individuals with a history of incarceration or commercial sex work

References

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Bickley, L. S. (2024). Bates’ guide to physical examination and history taking (13th ed.). Wolters Kluwer.

Cohen, P. & Gebo, K. (2025). COVID-19: Evaluation and management of adults with acute infection in the outpatient setting. UpToDate. Retrieved May 10, 2025 from https://www.uptodate.com/contents/covid-19-evaluation-and-management-of-adults-with-acute-infection-in-the-outpatient-setting

Goldenberg, D.L. (2024). Fibromyalgia: Clinical manifestations and diagnosis in adults. UpToDate. Retrieved April 10, 2025 from https://www.uptodate.com/contents/fibromyalgia-clinical-manifestations-and-diagnosis-in-adults

Hicks, C. B. & Clement, M. (2023). Syphilis: Epidemiology, pathophysiology, and clinical manifestations in patients without HIV. UpToDate. Retrieved April 10, 2025 from https://www.uptodate.com/contents/syphilis-epidemiology-pathophysiology-and-clinical-manifestations-in-patients-without-hiv

Jayanthi, N. (2025). Elbow tendinopathy (tennis and golf elbow). UpToDate. Retrieved June 3, 2025 from https://www.uptodate.com/contents/elbow-tendinopathy-tennis-and-golf-elbow

Khan, D. A., Banerji, A., Blumenthal, K. G., Phillips, E. J., Solensky, R., White, A. A., Berstein, J.A., Chu, D.K., Ellis, A. K., Golden, D. B. K., Greenhawt, M. J., Horner, C. C., Ledford, D., Lieberman, J. A., Oppenheimer, J., Rank, M. A., Shaker, M. S., Stukus, D. R., Wallace, D., & Wang, J. (2022). Drug allergy: a 2022 practice parameter update. Journal of Allergy and Clinical Immunology, 150(6), 1333-1393. http://doi.org/10/1016/j.jaci.2022.08.028

Krakower, D. S., & Mayer, K. H. (2025). HIV pre-exposure prophylaxis. UpToDate. Retrieved October 20, 2025 from https://www.uptodate.com/contents/hiv-pre-exposure-prophylaxis

New York State Department of Health. (2022). Expedited partner therapy: A summary for health care providers. New York State Department of Health. Retrieved June 3, 2025 from https://www.health.ny.gov/publications/3849.pdf

New York State Department of Health. (2025, February). Congenital syphilis information for providers. https://www.health.ny.gov/diseases/communicable/congenital_syphilis/providers/

Papp, J. R., Park, I. U., Fakile, Y., Pereira, L., Pillay, A., & Bolan, G. A. (2024). CDC laboratory recommendations for syphilis testing, United States, 2024. Morbidity and Mortality Weekly Report, 73(1). http://dx.doi.org/10.15585/mmwr.rr7301a1

Sax, P. E. (2024). Acute and early HIV infection: Clinical manifestations and diagnosis. UpToDate. Retrieved May 30, 2025 https://www.uptodate.com/contents/acute-and-early-hiv-infection-clinical-manifestations-and-diagnosis

Vazquez, J. A. (2024). Candidemia in adults: Epidemiology, microbiology and pathogenesis. UpToDate. Retrieved May 10, 2025 from https://www.uptodate.com/contents/candidemia-in-adults-epidemiology-microbiology-and-pathogenesis

Workowski, K. A., Bachmann, L. H., Chan, P. A., Johnston, C. M., Mou, S. A., & Centers for Disease Control and Prevention. (2021). Sexually transmitted infections treatment guidelines, 2021. MMWR. Recommendations and Reports, 70(4), 1–187. https://doi.org/10.15585/mmwr.rr7004a1

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Be Prepared for Your Nurse Practitioner Clinical Readiness Exam Copyright © 2026 by Elizabeth Heavey, Renee Biedlingmaier, Colleen Burgoyne and Carnel C. Jackson is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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