[NP-Clinical] Derm

[Lisa Meyer]

Another Derm question for all...
 
I had a 20 something, very anxious, caucasion, heterosexual male yesterday that presented to the emergency dept. initially with a complaint of a "cold-sore in my nose".  It had been increasing over 2 weeks time.  R nasal mucosa was tender, erythematous and had yellow crusts.  He had not had a similar lesion before.  I told him that I though he likely had impetigo, not a cold sore, and advised antibiotic.  He then asked me if I could do "a bunch of labs to see if I'm alright".  Confused, I asked him what he thought might be wrong.  At first, he says that he coughs sometimes and he's a smoker, so he thinks maybe he has cancer.  After discussing this with him for some time and offering him a family practice referral (he had no primary), he blurts out that "Well what if I think I have an STD?!"   
 
Now we're getting to the issue... He noted some red spots on his penis 2 days ago.  They have not changed since he noted them.  They do not itch or cause discomfort.  There has been no drainage or crusts.  No penile discharge or dysuria.  Single "one-night stand" new partner sexual encounter 2 months ago.  Denies fever or chills.  Reports fatigue over the last few months and lightheadedness off and on--"probably related to my terrible diet".  There are 5-6 small (1-2 mm) round and oval, erythematous lesions that are flat, some appear perhaps slightly ulcerated.  They are shiny (almost appear moist) but dabbing with cotton tipped applicator did not reveil drainage.  No crusts.  Non tender.  Not vesicular, and certainly did not appear as any herpes I've ever seen before--lesions not clustered, but diffusely scattered around the distal 1/4 of the shaft.  None on the glans.  

Any clues?  Could they somehow be related to the impetigo I diagnosed in the nose?  I've never seen penile impetigo and these were not crusty, but I've got no other ideas.  

Lisa
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