Daniel DeMarco Focused H&P#7 Ambulatory Care

Chief Complaint: Rash on Right Under Arm x 2wks

 

History of Present Illness:

DK is a 25yo Male presenting to office with complaint of Rash on Right Under Arm x 2wks. States that it occurred after going down a “dry slip and slide” on 7/4/2019. Worse with touching the area or applying underarm deodorant. Reports the rash is improving. Denies fever, chills, pruritis, history of immunocompromising conditions.

 

Also requesting STD screening at this visit. New partner x several months and would like to be checked. Denies penile discharge, dysuria, frequency, hematuria, oral lesions.

 

Allergies: NKDA

Medications: Denies

PMH: Denies

PSH: Denies

Social History: Admits social EtOH use. Denies tobacco use, marijuana use, other illicit drug use.

Sexual History: Identifies as male. Has one female partner. No history of STDs. Uses condoms with every sexual encounter.

Family History: Denies

 

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 under arm. Denies bruising, petechiae

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

 

Physical Exam:

Vital Signs:

BP: 130/80

Pulse: 60bpm

RR: 14 breaths/min

Temp: 37.0C

SpO2: 98%RA

Ht: 63.0  inches

Wt: 73kg

 

General Survey: Alert, NAD. Appears stated age.

Skin: Right underarm area: mild erythematous patch of 2mm papules. Mild tenderness to palpation. No warmth. No purulent drainage.  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.

Abdomen: Nondistended. BS +. Soft, non-tender. No guarding, rebound tenderness. No hepatosplenomegaly.

 

Assessment/Plan:

DK is a 25yo Male with 2 week rash on right under arm area that occurred 2/2 irritation that is improving and that does not appear infected consistent with irritant contact dermatitis.

 

#Irritant Contact Dermatitis on Right Under Arm – Improving

– Start OTC Neosporin to aa bid until resolution

– If fevers, chills, lymphatic streaking, purulent drainage RTC or go straight to ER

 

#STD Screening

– RPR

– Hep (A, B, & C) Infection Panel

– Herpes Type 1

– Herpes Type 2

– HIV

– Urine N. gonorrhoeae and C. trachomatis

 

Follow-Up: prn

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student