How to Take a History and Examine a Monkeypox Patient

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2 months ago

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I’m sick and tired of gay men being misdiagnosed with something ELSE when it’s clearly monkeypox and you can’t be bothered to examine them or take a history, doctors. THIS IS NOT ROCKET SCIENCE Take two✌️ minutes and let me catch you the fuck up.

Seeing a patient with a new rash, especially if it: —is around their genitals 🍆or anus🍑? —has another new distant lesion (face, arms) —looks like papules, vesicles, pustules, or ulcers —is in a gay man, esp with new partners? Yeah. It's probably monkeypox.

So you put on your big boy PPE (I double glove because I'm often touching my phone for photos or swabbing lesions) and talk to the patient. You ask them these straightforward questions (this is called "taking a history.") No one is going to care that you're in PPE. It's FINE.

These patients are scared and in severe pain. Many are healthy and young and have literally never had a medical problem before. All they want is your help. They would not wish monkeypox on their worst enemy. They do not want you to get monkeypox from helping them.

You ask them some additional questions: —Anyone you're aware of have monkeypox recently? —Do you know your HIV status? —Can I test you for other STDs today? (30% of MPX patients have had other concurrent STDs) —Have you had a fever, headache, or swollen lymph nodes recently?

🌈Gay men are legit the simplest patients to take a history from. Seriously. When did the headache start? They can tell you what they were doing when it started. How high was the fever? It's on their camera because they texted the thermometer picture to their friend. Easy mode.

Fever/lymph node swelling is common but not present in everybody, but often the lymph nodes are a dead giveaway for monkeypox (but keep your differential open!) Rectal pain is another common presentation of monkeypox. Ask about it.

Now you *examine the patient*. This is where you will look and touch their body. Most people will know where they have noticed lesions, because they have probably looked themselves up and down already many times, and have taken photos on their phone.

Ask about lesions in the mouth, people usually know if they have any. Ask about other rashes too, since MPX can present with a generic maculopapular rash along with pox. https://twitter.com/grahamwalker/status/1552817990906744832?s=20&t=gLf9nsAyNlwkZNZ_zeDd4w

Also: 10% of people will have only ONE SINGLE LESION. None of this "monkeypox is ruled out, there would be more lesions" nonsense. I can't.

Okay, now look at their genitals/lesions in sensitive areas. Patients have no problem moving their junk around so you can get a good view, swab, get photos.

Early in the dz I think there are many more false negative swabs: if the lesions aren't open, you're probably not getting nearly as much of a sample. I have started asking patients what their lesions looked like and when they were swabbed — if they weren't open, maybe false neg.

I've had 1 pt that had what looked like "folliculitis that wasn't going away" on his face and 1 lesion on his groin, but had all the other symptoms — fever and lymph nodes, severe rectal pain. I did anoscopy with LOTS OF VISCOUS LIDO and saw multiple lesions. Voila, monkeypox.

Could it be herpes or something? I mean, I guess. You can send an HSV swab if you want, no one will fault you. And sure, there are gonna be some herpes outbreaks as well. But especially if they have other symptoms, or many lesions? Yeah, it's probably not herpes then.

I'm offering multi-modal pain meds to these patients: motrin, tylenol, opiates, topical lidocaine, and a trial of gabapentin and mesalamine suppositories (the last two I've heard some colleagues having success with and I think are very low risk to try). Sitz baths might help too.

Don't forget to test for other STDs—or have them do it themselves. Swab their throat and butt for GC/C, test for syphilis and HIV. Or refer them somewhere that can. And if they're not on HIV PREP and having unprotected sex, sounds like PREP might be right for them.

These patients need to isolate, and if they're in the "yeah this definitely seems like monkeypox" category and it's early in their disease, they can get post-exposure vaccine. Talk with your county health dept or your ID or HIV doc to get them connected.

I have never met patients more grateful to be seen. Despite hours w long waits. Honestly. These patients are so scared, in so much pain, and so desperate for someone—anyone—to talk to them and examine them and help them. You can be that someone, wear your PPE, and be at no risk.

Sorry for the cursing eaerlier but this is the 2nd pandemic that I've been volunteered to be the front line for, while seemingly most of medicine can't even be bothered to take a proper history from the comfort of their telephone or video visit for these patients. I'm tired.

These patients think I’m some kind of miracle worker for just talking to them and examining them. The federal government has let them down. They can't get vaccinated. They can't get treated. They can't even be seen. And when we fail them too? A pox on the house of medicine.