HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who has two complaints. First complaint is neck pain on the left lateral side of her neck. It started at approximately 2:00 a.m., and it makes it difficult for her to find a position that is comfortable or that she can sleep in. She has not taken any over-the-counter medications for this pain. She has never had any pain like this before.
She denies any numbness, tingling or weakness in her upper extremities. She denies any trauma, including no car accidents, no falls. The only thing that she did a little bit differently yesterday was she did play with her children. She notes no trauma there either. The second complaint is a rash that she has had for a month that she notes over her chest wall, abdomen, upper back and upper shoulders. It occasionally itches. She thinks it looks flat and that sometimes it is white and that sometimes the skin is red. No one else at home has this. She has never had anything like this before the past month.
PAST MEDICAL HISTORY: Previous globe rupture that was surgically repaired.
MEDICATIONS: None.
ALLERGIES: None.
SOCIAL HISTORY: The patient smokes and denies any alcohol or drug use.
REVIEW OF SYSTEMS: As per HPI. All other systems negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 106/58, pulse 78, respiratory rate 18, and temperature 97.6.
GENERAL: This is a well-nourished, well-developed Hispanic female in no acute distress.
HEENT: Head is atraumatic and normocephalic. PERRLA. EOMI. Oropharynx is pink and moist.
NECK: The patient has some decreased range of motion with flexion, extension, lateral rotation, and lateral flexion and extension. Palpation-wise, she had some paraspinal muscle tenderness and spasm on the left. She had 5/5 strength in her upper extremities and +2 symmetric reflexes in her upper extremities. She had a normal gait and no focal deficits.
SKIN: Warm and dry on her chest wall, abdominal wall, and upper back. She had multiple flat hypopigmented macular lesions, some of which coalesced into larger plaques. These were nonraised with some slight bit of scaling and irregular borders that were slightly erythematous. She had no lesions on her arms, legs or face.
MEDICAL DECISION MAKING: The patient has what sounds like a neck muscle spasm or neck strain but no evidence of trauma. We did not feel it necessary to perform any radiographic analysis. As far as her skin lesions are concerned, the initial diagnosis is tinea versicolor.
We did speak with Dermatology as far as treatment options, and they recommended both ketoconazole pills and a shampoo or lotion. Based on the extensive nature of this, it was informed to the patient that if this is tinea versicolor, it is a chronic condition that cannot be eradicated but more managed in a chronic setting. The patient was amenable to this plan, and she was given prescriptions for a ketoconazole pill to take today as well as in one week and ketoconazole shampoo to wash with daily for the next two weeks and then weekly for life.
If there is no improvement in her symptoms in the next one to two weeks, she was advised to contact either her primary care doctor, she currently has none, or the dermatology clinic for followup and further evaluation of this rash. It certainly does not appear superinfected at this point to need any sort of antibiotics or anything.
CLINICAL IMPRESSION:
1. Tinea versicolor.
2. Acute neck strain.
PLAN:
1. Flexeril for the neck pain as well as ibuprofen or Tylenol over-the-counter.
2. Ketoconazole as prescribed, listed above.
3. Return to the ER for numbness, tingling or weakness in your extremities or any other neurologic concerns.
4. If no improvement in one to two weeks, please follow up with Dermatology.
DISPOSITION: The patient was discharged to home in stable condition.
