CHIEF COMPLAINT: Generalized body rash.
HISTORY OF PRESENT ILLNESS: The patient has noted a rash over his arms, legs, abdomen, and back over the last one to two days. He has used some over-the-counter cortisone cream as well as Aveeno baths with minimal to moderate relief of symptoms. The rash first started on his left buttock area, and it has now since spread to his hands, legs, and torso. He states that he has been working in the woods and stated that he was working around poison ivy.
PAST MEDICAL HISTORY: ADHD.
MEDICATIONS: Over-the-counter creams as mentioned in the HPI.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient does smoke about half a pack of cigarettes a day, minimal alcohol use, minimal marijuana use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As mentioned. Otherwise, negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 116/68, pulse 80, respirations 16, temperature 96.8, and pulse ox 98% on room air.
GENERAL: The patient is awake, alert, and oriented, in no acute distress.
LUNGS: Good breath sounds bilaterally with no wheezes, rales or rhonchi.
HEART: Regular rate and rhythm with no murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, and nondistended. Good bowel sounds with no organomegaly.
EXTREMITIES: No clubbing, cyanosis or edema.
SKIN: The patient has erythematous, mildly raised vesicular rash over his hands, arms, torso, both anteriorly and posteriorly in bilateral lower extremities. There is no evidence of any bleeding or any seepage.
EMERGENCY DEPARTMENT COURSE: The patient was given 10 mg of Decadron IV for palliative care of acute contact dermatitis. He tolerated the IV well. He was seen and evaluated for contact dermatitis and was given instructions on what to do while home.
DISCHARGE DIAGNOSIS: Acute contact dermatitis.
DISCHARGE PLAN:
1. He was given Medrol Dosepak to take as directed as well as Atarax 50 mg to take q. 6 hours p.r.n. for itching and acute rash.
2. He was advised to wash all his clothes separately.
3. He was advised that he can continue taking the Aveeno baths as recommended.
4. He should not take Benadryl as he was given Atarax.
DISPOSITION: The patient was discharged home in stable condition.
