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 presenting to clinic /c no significant PMH, c/o rash on body x 1 week. Patient developed rash 7 days ago after day at construction site. Patients states rash started on legs and spread up to stomach and arms.  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, n/v/d or urinary symptoms. He denies recent travel, toxic chemical exposures, medication changes, numbness, tingling 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: Construction Worker

 

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 widespread erythematous, papular rash and some vesicular lesions with some whitish yellow covering abdomen, upper extremities,lower extremities, between web spaces of fingers and toes. Lesions measure 2mm by 2mm.

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. No erythema, discharge or foul smell.

GU: Not assessed

Rectal: Not assessed

Peripheral Vascular: Pulses normal, no cyanosis no edema.

MSK: Not assessed

Neuro: Not assessed

 

 

DDx

  1. Contact Dermatitis/Seborrheic
    1. +Itching, inflammation
    2. Usually resolves 7-10 days
    3. –scaly patches, red skin on sides of nose, face etc
  2. Scabies
    1. +papular lesions
    2. +pruiritic rash
    3. +red bumps and yellow blisters on skin, widespread, crusted rash
  3. Psoriarsis
    1. +itchy and painful
    2. –red, bumpy patches
    3. –covered in silvery scales

 

Labs/Testing: none

 

Assessment & Plan

39 y/o M presenting to clinic c/o of  rash x 7 days that begin on lower extremeties and spread to upper extremeties. Extensive widespread erythematous, papular rash and some vesicular lesions with some whitish yellow covering abdomen, upper extremities,lower extremities, between web spaces of fingers and toes. Lesions measure 2mm by 2mm. Pt admits to severe pruritus which worsens at night. Pt clinical findings most consistent with scabies.

 

  1. Scabies
    1. Permethrin Cream- Apply overnight to all areas of body. Including face and scalp
    2. 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, typically4-6-week incubation period with primary exposure, 1-3 days for 2ndary exposure. Take precaution can spread/acquired sexually, avoid contact with others, avoid itching. Family members/spouses should be evaluated. Linens/clothes should be washed in hot water. Return to clinic if symptoms worsen.

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