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3 months ago

662 words

Samer Khawaja

Rotation 1, Ambulatory Care

StatCare Hicksville

H&P #1

 

Visit Date: 1/09/2019

 

Patient: Mr. S

Age: 39

Race: Asian

Informant: Pt himself, reliable.

 

CC: “irritating rash” x1 week

 

HPI: 39 y/o male /c no significant PMH, presents to clinic c/o rash on body x 1 week. Patient developed rash 7 days ago, after mowing the lawn. Rash covers upper and lower extremities and chest and back. Admits severe itching that is worse at night. He has never had a rash like this before. Pt applied cortisone 10 with minimal relief. He denies fevers, chills, SOB, chest pain, myalgia, arthralgias, abdominal pain, nausea, vomiting, diarrhea, or urinary symptoms. He denies recent travel, toxic chemical exposures, medication changes, infections or sick contacts.

 

PMH: None

 

PSH: Appendectomy 2016

 

PH: None

 

Meds: None

 

Allergies: Sulfa

 

Immunizations

  • Up to date
  • Flu shot 2018

Family Hx:

  • Mother: Alive 70s, Diabetes
  • Father: Alive 80s, CAD

Social Hx:

  • Caffeine/coffee x4 a day
  • Denies drugs, smoking/tobacco/illicit drug use
  • Alcohol: socially, 1-2 drinks per week
  • Marital Status: Married, Sexually active with wife, use protection
  • Exercise/Diet: Works out x5 a week, eats x4 meals a day
  • Occupation: NYPD officer

 

ROS

General: Denies fever, night sweats, chills fatigue, weakness

Skin, hair, nails: SEE HPI

Head: Denies h/a, vertigo, lightheadedness

Eyes: Denies glasses, blurring or recent visual disturbances

Ears: Denies hearing loss, pain, discharge and tinnitus,

Noses/sinuses: Denies discharge, epistaxis, obstruction

Mouth/throat: Denies bleeding gums, sore tongue, sore throat, mouth ulcers

Neck: Denies localized swelling/lumps, stiffness or decreased ROM

Breast: Denies lumps, nipple discharge, pain

Cardiac: Denies murmurs, palpitations, DOE, orthopnea, CP

Respiratory: Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, PND

GI: No appetite changes. Regular BMs. No blood in stool .

GU: Denies urgency, dysuria, changes in frequency, hesitancy, dribbling

MSK: Denies arthralgias, swelling, joint pain or back pain

Peripheral Vascular: Denies claudication, trophic changes, peripheral edema

Heme: Denies anemia, easy bruising or bleeding, lymph node enlargement

Endo: Denies polyuria, polydipsia, polyphagia, heat/cold intolerance, goiter, hirsutism

Nervous: Denies seizures, tingling/numbness, sensation changes.

Psych: Denies little interest or pleasure in doings things. No feelings of depression or hopelessness

 

PE

General Appearance: Alert and oriented. Appears documented age. Small build. Good hygiene and grooming. Posture, gait not assessed. Patient in no acute distress.

 

Vitals

Temp: 97.8 F

HR: 70 bpm, RRR

BP: sitting 131/79 Right arm

Ht:  69”

Wt:  140#

BMI: 20.67 kg/m^2

RR: 17 breaths per min, unlabored

O2 Sat: 98

Pain Scale 0

 

Skin: Extensive erythematous, elevated pruritic diffuse, papular rash along upper and lower extremities including trunk/back

Hair: Average quantity and distribution

Nails: cap refill <2 secs. No clubbing present

Head: normocephalic, atraumatic, Non tender to palpation

Eyes: Not assessed

Ears: Not assessed

Nose: Not assessed

Sinuses: Not assessed

Throat: Not assessed

Heart: RRR, Normal S1, S2. No murmurs heard. PMI in 5th ICS midclavicular No heaves, thrills noted

Lungs: Clear to percussion and auscultation bilaterally. No crackles, rhonchi, rales. No use of accessory muscles noted. Non tender to palpation bilaterally. Negative increase in tactile fremitus throughout.

Breasts: Not assessed

Abdomen: Symmetrical, ND/NT. BS present in all 4 quadrants. No bruits. Tympany to percussion throughout. Non tender to palpation. Neg CVAT bilaterally

GU: Not assessed

Rectal: Not assessed

Peripheral Vascular: Pulses normal, no cyanosis no edema.

MSK: Not assessed

Neuro: Not assessed

 

 

DDx

  1. Contact Dermatitis/Poison Ivy
  2. Scabies
  3. Stress

 

Labs/Testing: none

 

Assessment & Plan

39 y/o M presenting to clinic c/o of

  1. Scabies
    1. Permethrin Cream- Apply overnight to all areas of body. Including face and scalp
    2. Prednisone 20mg tablets, 2 tablets QID x5 days
    3. Benadryl 25-50mg, PO, q4-6 hours PRN for pruritus

 

Patient Education

Scabies is contagious, it is spread by direct skin to skin contact with person infested with scabies, typically 4-6-week incubation period with primary exposure, 1-3 days for 2ndary exposure. Take precaution can spread/acquired sexually Family members/spouses should be evaluated. Linens/clothes should be washed in hot water.

 

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