Identification:

• Name: J.H.
• Sex: Male
• Race: Hispanic
• Nationality:
• Age: 64
• Marital Status:
• Address:
• Religion:

Informant:

• Source of hx: Self
• Competency: Competent

 

Referral Source:

CC: “ I have a rash on my back” x 4 days

HPI:

64 y/o male with no pmhx presents to the office for the first time complaining about a rash on his back x 4 days. Pt states that about 1 week ago he started to feel itchy, especially at night when he would go to bed, but he did not think much of it. Pt started to notice red spots on his neck and shoulders about 5 days ago, and 4 days ago, when he looked at his back in the mirror, he noticed that his entire back was covered with red spots. Per patient, these red spots are not painful. He is itchy all over his body, but it is more concentrated in the back. Pt states that he is most itchy when he lays down in bed, and is least itchy after a hot shower or if he is walking outside. Pt has not tried any lotions or ointments to help relieve the itch. Pt states that he shares his apartment with roommates who are not showing similar symptoms. Pt denies any allergies to food or medication, fever, being in contact with anyone with similar presentation, recent travel, cough, fatigue.

 

Pmhx:

None

 

Past surgical hx:

• None

Medications:

• None

Allergies:

• No known food, environmental or drug allergies.

Family hx:

• None

Social Hx:

• Denies using drugs, tobacco, alcohol use, recent travel.

General:

• Denies fever, chills, fatigue, loss or gain of weight, N/V, diaphoresis, loss of appetite and night sweats.

Skin, hair and nails:

• Skin has red discoloration on several areas of the patients body
• Denies change in texture to skin, hair and nails, excessive dryness, sweating, moles/rashes, pruritis, and change in hair distribution.

Eyes:

• Wears glasses. Denies visual disturbances, lacrimation, photophobia, itching, corrective lenses, blurriness, and discharge.

HENNT:

• Denies headaches, vertigo, head trauma
• Denies hearing loss, tinnitus, pain, discharge, wearing hearing aids
• Denies epistaxis, discharge, obstruction, rhinorrhea, stuffiness, sneezing, allergies
• Denies swelling/lumps, stiffness, or decreased ROM
• Denies sore throat, neck pain, hoarseness, bleeding in mouth/throat, sore tongue, mouth ulcers, voice changes or wearing dentures.

Pulmonary:

• Denies cough, wheezing, SOB, pain on inspiration, hemoptysis, orthopnea, cyanosis, PND, clubbing, or any history of asthma.

Cardiovascular:

• Denies CP, HTN, edema, palpitations, irregular heartbeats, syncope, claudication, murmurs, and orthopnea.

 

Gastrointestinal:

• Denies indigestion, intolerance of foods, N/V, diarrhea, jaundice, bleeding (oral or anal), hemorrhoids, constipation any change in BM, dysphagia, pyrosis, flatulence, blenching or burping, rectal bleeding and abdominal pain.

Genitourinary:

• Denies frequency, nocturia, urgency, dysuria, oliguria, lesions, discharge, hematuria, pyuria, dyspareunia, any flank pain.
• Denies hesitancy or dribbling

Nervous System:

• Denies seizures, headache, LOC, loss of strength, change in cognition, mental status, memory, ataxia, sensory disturbances, syncope, slurring of speech, focal weakness, neck stiffness, any decrease in sensation, and tingling.

MSK:

• Denies joint/muscle pain, deformity, swelling, redness, arthritis.

Peripheral Vascular System:

• Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, color change.

Hematologic System:

• Denies new or known bruising, bleeding, petechiae, purpura, blood transfusions, lymph node enlargement, hx of DVT/PE and anemia

Endocrine:

• Denies polyphagia, polyuria, polydipsia, intolerance to heat/cold, goiter, excessive sweating or hirsutism.

Psychiatric:

• Denies depression/sadness, suicidal ideation, anxiety, seeing a mental health specialist, memory deficits, OCD, and taking medication for mental illness.

 

Physical

General:

• Thin male, well nourished, in no acute distressed. Acceptable hygiene appears age stated. Is alert and cooperative

Vitals:

• BP: R
  1. Seated Not Done
• R: 17 breaths/min, unlabored
• P: 66 beats/min, regular
• T: 9 degrees F (oral)
• O2 Sat: Not tested
• Height 5 feet 7 inches   Weight 123 lbs.   BMI: 19.3

Skin:

• Several erythematous macules noted on the posterior neck and shoulders, as well as posterior aspect of arms and superior truck.
• Warm and moist, good turgor, nonicteric, no lesions, scars, or tattoos.

Head:

• No scars, bumps, trauma, tenderness to palpation, normocephalic, atraumatic

Hair:

• Average quantity and distribution

Nails:

• No clubbing, cap refill <2 seconds throughout.

Eyes:

• symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white, no icterus; conjunctiva & cornea clear. Visual acuity not tested. Visual fields full OU. PERRLA. EOMs full with no nystagmus.

Ears:

• Symmetrical and normal size. No evidence of lesions/masses / trauma on external ears. No discharge / foreign bodies in external auditory canals AU.   TM’s pearly white / intact with light reflex in normal position AU. Auditory acuity intact to whispered voice AU.

Nose:

• Symmetrical / no obvious masses / lesions / deformities / trauma / discharge.   Nares patent bilaterally / Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions / deformities / injection / perforation.   No evidence of foreign bodies.

Sinuses:

• Non-tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.

Lips:

• Pink, moist; no evidence of cyanosis or lesions.

Mucosa:            

• Pink; well hydrated.   No masses; lesions noted. No evidence of leukoplakia.

Palate:

• Pink; well hydrated.   Palate intact with no lesions; masses; scars.

Teeth:

• Decent dentition / no obvious dental caries noted.

Gingivae:

• Pink; moist. No evidence of hyperplasia; masses; lesions; erythema or discharge.

Tongue:

• Pink; well papillated; no masses, lesions or deviation noted.

Oropharynx:

• Well hydrated; no evidence of injection; exudate; masses; lesions; foreign bodies. Tonsils absent, no hx of removal. Uvula pink, no edema, lesions

Neck:

• Good ROM. Trachea midline.   No masses; lesions; scars; pulsations noted.   Supple; non-tender to palpation. No stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no palpable adenopathy noted.

Thyroid:

• Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Chest:

• Symmetrical, no deformities, no evidence trauma.   Respirations unlabored / no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1.

Lungs:

• Clear to auscultation and percussion bilaterally.   Chest expansion and diaphragmatic excursion symmetrical.   No adventitious sounds. No rales, Rochi, or wheezing heard.

Heart:  

• Carotid pulses are 2+ bilaterally without bruits. RRR; S1 and S2 are normal. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs or other extra sounds.

Abdomen:

• Flat / symmetrical / no evidence of scars, striae, caput medusae or abnormal pulsations.BS present in all 4 quadrants. No bruits noted over aortic/renal/iliac/femoral arteries. Non-tender to percussion or to light/deep palpation.   No evidence of hepatomegaly or splenomegaly. No masses noted.   No evidence of guarding or rebound tenderness.   No CVAT noted bilaterally.

Peripheral Vascular:

• The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally (no C/C/E B/L) No stasis changes or ulcerations noted.

Mental Status:

• Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted.

Cranial Nerves:

• I – Intact no anosmia.
• II- Visual fields by confrontation full.
• III-IV-VI- PERRL, EOM intact without nystagmus.
• V- Facial sensation intact, strength good. Corneal reflex not tested.
• VII- Facial movements symmetrical and without weakness.
• VIII- Hearing grossly intact to whispered voice bilaterally.
• IX-X-XII- Swallowing and gag reflex intact. Uvula elevates midline. Tongue movement intact.
• XI- Shoulder shrug intact. Sternocleidomastoid and trapezius muscles strong.

 

Motor/Cerebellar:

• Full active/passive ROM of all extremities without rigidity or spasticity. Normal muscle bulk and tone throughout. No atrophy, tics, tremors or fasciculations. Strength equal and appropriate for age bilaterally (5/5 throughout). No Pronator Drift. Gait normal with no ataxia. Romberg negative.

Sensory:

• Intact to light touch, sharp/dull, vibratory, proprioception, point localization, testing bilaterally.

Meningeal Signs:

• No nuchal rigidity noted.

MSK LE:

• No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted FROM (Full Range of Motion) of all upper and lower extremities bilaterally. No evidence of spinal deformities.

MSK UE:

• No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted FROM (Full Range of Motion) of all upper and lower extremities bilaterally. No evidence of spinal deformities.

 

Assessment:

64 y/o male with no pmhx presents to the office for an itchy rash on his back x 4 days. All clinical findings indicate possible scabies.

DDx:

• Scabies
• Chicken Pox
• Allergic Reaction
• Erythema Multiform
• Fungal Infection

Plan:

• Itchy Rash
  1. Permethrin Topical- apply to the neck and soles of the feet
  2. Follow up after one week
  3. Educate patient about skin to skin contact
  4. Change bed sheeting