Daniel DeMarco Focused H&P#3 Ambulatory Care

Chief Complaint: Rash on Right Upper Arm x 2d

 

History of Present Illness:

JS is a 62yo Male with PMH HTN presenting to office with complaint of Rash on Right Upper Arm x 2d. Patient states the rash started as one bump and was initially itchy. Admits scratching. Patient states that more bumps came up and the rash became burning and tingling. States that there was fluid within the bumps that eventually began drying up. States that the area is painful when touched. Denies fever, chills, nausea, vomiting, poison ivy exposure, exposure to other irritants.

 

Allergies: NKDA

Medications: Losartan-HCTZ 100mg/12.5mg 1 tab PO qd

PMH: HTN

PSH: Denies

Social History: Admits social EtOH use. Former tobacco use – 2packs per day x 15 years = 30 Pack-Year History. Denies marijuana use, other illicit drug use.

Sexual History: Identifies as male. Has one female partner. No history of STDs.

Family History: Unknown

 

Review of Systems:

General: Denies fever, chills, anorexia, weight loss, weight gain

Neuro: Denies HA, trauma, LOC, seizure activity, developmental delays 

HEENT: Denies change in vision, hearing, pruritus, photo/phonophobia, neck pain, runny nose, ear pain, congestion, sore throat

CV: Denies shortness of breath, sweating, color changes with feeding, chest pain, palpitations, history of murmur, fainting, or dizziness with activity 

Respiratory: Denies wheezing, shortness of breath, cough

GI: Denies nausea, vomiting (bloody/bilious), diarrhea, constipation, hematemesis, hematochezia, or melena

GU: Denies dysuria, frequency, urgency, hematuria

Endo: Denies polyuria/polydipsia, heat/cold intolerance, growth pattern abnormalities

MS: Denies myalgias, arthralgias, trauma, limp, weakness

Skin: Admits rash on Right Upper Arm. Denies bruising, petechiae

Psychiatric: Denies HI/SI, feelings of helplessness, hopelessness

 

Physical Exam:

Vital Signs:

BP: 144/94

Pulse: 92bpm

RR: 16 breaths/min

Temp: 37.1C

SpO2: 100%RA

Ht: 69.0 inches

Wt: 73kg

 

General Survey: Alert, NAD. Appears stated age.

Skin: Right Upper Arm, Skin Above Triceps Region – multiple crusted over vesicles, multiple papules, moderate erythema, tender to palpation, warm to touch. No jaundice, cyanosis, mottling. 

Hair: Average quantity and distribution.

Nails: Capillary refill <2s throughout.

Cardiovascular: Regular rate and rhythm. S1 and S2. No murmurs, gallops, rubs.

Chest and Pulmonary: Symmetrical rise and fall of chest wall. No labored breathing, accessory muscle use. Clear to auscultation bilaterally.

 

Assessment/Plan:

JS is a 62yo Male with 2d complaint of worsening Right Upper Arm vesicular ash that started as itching and is now burning consistent with Zoster and erythema, tenderness, and warmth concerning for cellulitis.

 

#Herpes Zoster

– Start Valacyclovir 1000mg PO tid x 7d

– Start Ibuprofen 600mg PO q6h prn for pain x 7d; Do not exceed 2400mg/day

 

#Cellulitis

– Start Sulfamethoxazole/trimethoprim (Bactrim) 160mg PO 12h x 7d

– If fever, chills, inability to tolerate PO, lymphatic streaking, go straight to ER

 

Follow-Up: 3 Days (7/17/2019) for reevaluation of Rash

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student