DATE OF SERVICE: MM/DD/YYYY
CHIEF COMPLAINT: Bumps on body.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Asian female who complains of a rash to her bilateral axillae as well as several areas of rash to her abdomen and arms for the past two weeks. She states it has been worse over the last one week. She states the areas are very pruritic but denies any pain. She denies any purulent drainage. She denies any fevers or chills, difficulty breathing or swallowing. The patient denies any new soaps, lotions or detergents. She denies using any new deodorant.
PAST MEDICAL HISTORY: None.
MEDICATIONS: None.
ALLERGIES: None.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient denies tobacco, alcohol or illicit drug use.
REVIEW OF SYSTEMS: As above, otherwise negative per the patient.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 102/66, pulse 86, respirations 18, temperature 97.8, and O2 sat is 99% on room air.
GENERAL: Well-developed, well-nourished female, in no acute distress.
HEART: Regular rate and rhythm. No murmurs, gallops or rubs.
LUNGS: Clear to auscultation bilaterally.
SKIN: The patient does have two areas of maculopapular rash noted to her bilateral axillae. There is no purulent drainage noted. There is no fluctuance, erythema or edema. There is no tenderness to palpation along the areas. The patient does have one small maculopapular area noted to her left abdomen. She also has one area of rash to her left arm. Otherwise, there are no other rashes noted. Skin is, otherwise, warm and dry to touch.
EMERGENCY DEPARTMENT COURSE AND MEDICAL DECISION MAKING: The patient’s nursing notes were reviewed. At this time, the patient most likely has either contact dermatitis or a fungal-type rash. We will treat her for both with a combination antifungal cream and a steroid cream. We will give her the dermatology clinic number for followup and encourage her to keep her axillary areas clean and dry.
DIAGNOSIS: Dermatitis, not otherwise specified.
PLAN:
1. The patient is given Lotrisone cream.
2. She is to keep the areas clean and dry.
3. Call the dermatology clinic for an appointment.
4. Return to the ER for any worsening symptoms.
DISPOSITION: The patient was discharged to home in good condition.
