A 32‑year‑old man presented with a persistent sore on his lower lip that had lasted three weeks and failed to respond to topical antibiotic cream. Strikingly, the ulcer caused no pain. He denied any history of lip biting, dental injury, or trauma. However, he reported oral‑genital sexual contact about 17 days before the sore appeared — a detail that proved crucial.

On examination, the lesion was well‑defined, firm, and measured 1.5 cm, with a clean base and slightly enlarged but non‑tender lymph nodes under the chin. Blood tests ruled out HIV and herpes, but syphilis serology (TPHA positive, VDRL titre 1:64) confirmed the diagnosis: primary syphilitic chancre of the lip.

Treatment with a single intramuscular injection of benzathine penicillin G led to complete healing within two weeks. By three months, the patient’s antibody levels had fallen fourfold. The case was reported by Dr. Ahmed Bakr Elazab and Dr. Ahmed Ibrahim (Department of Dermatology, Andrology & STDs, Faculty of Medicine, Suez University, Egypt) and Dr. Islam Mohamed Eldisoky (Sheikh Jaber Al‑Ahmad Al‑Sabah Hospital, Kuwait).

A 32‑year‑old man presented with a persistent sore on his lower lip that had lasted three weeks and failed to respond to topical antibiotic cream. Strikingly, the ulcer caused no pain. He denied any history of lip biting, dental injury, or trauma. However, he reported oral‑genital sexual contact about 17 days before the sore appeared — a detail that proved crucial.

On examination, the lesion was well‑defined, firm, and measured 1.5 cm, with a clean base and slightly enlarged but non‑tender lymph nodes under the chin. Blood tests ruled out HIV and herpes, but syphilis serology (TPHA positive, VDRL titre 1:64) confirmed the diagnosis: primary syphilitic chancre of the lip.

Treatment with a single intramuscular injection of benzathine penicillin G led to complete healing within two weeks. By three months, the patient’s antibody levels had fallen fourfold. The case was reported by Dr. Ahmed Bakr Elazab and Dr. Ahmed Ibrahim (Department of Dermatology, Andrology & STDs, Faculty of Medicine, Suez University, Egypt) and Dr. Islam Mohamed Eldisoky (Sheikh Jaber Al‑Ahmad Al‑Sabah Hospital, Kuwait).

About The Study: The 21st Century Cures Act mandated that patients have immediate access to clinical notes and other health information (i.e., open notes). At a large, integrated health system, open notes engagement increased rapidly following implementation and plateaued at 55% within 2 months, with substantial sociodemographic disparities in engagement. These disparities may be attributed to the digital divide. Language may be another barrier, as notes are not routinely translated despite multilingual portal interfaces.