CHIEF COMPLAINT: Rash.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female who presents with sores on her hands for the last two weeks. The patient states that initially the area started out as a sore in her right palm and then began to have other sores develop on both the right and left hand, on both palmar and dorsal aspects. She denies any purulent drainage or erythema to the area. She denies any fevers or chills. She states that she works mostly with dogs and cats but no other exotic animals. The areas have been pruritic and flaky, but she denies any pain to the area. She denies any sores to her feet or any other part of her body. She has been putting antibiotic ointment on the areas without any relief.
PAST MEDICAL HISTORY: None.
ALLERGIES: None.
MEDICATIONS: None.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient denies tobacco, drinks alcohol occasionally, and denies any illicit drug use.
REVIEW OF SYSTEMS: As above, otherwise negative per the patient.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 116/74, pulse 64, respirations 18, temperature 98.6, and O2 sat 98% on room air.
GENERAL: This is a 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 an approximately 2 cm in diameter area of flaking skin to her right hand. There are also several other areas of flaking, tinea-like rash to her hands. There are no other rashes noted to the skin. 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’s rash does resemble most likely a tinea rash. We will give her Lotrimin cream and encouraged her to wear gloves at work. We will give her a clinic list so that she may obtain a primary care physician.
DIAGNOSIS: Tinea corporis.
PLAN:
1. The patient is given Lotrimin cream. She is to wear gloves at work. Follow up with community clinic of choice.
2. Return to the ER for any worsening symptoms.
DISPOSITION: The patient was discharged to home in good condition.
