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QUESTION
A 28-year-old-male presents to the office complaining of itching & a rash after hiking in the woods over the weekend. He states he was wearing long pants and a short sleeve shirt. States the rash is “really bad” and keeps him awake at night. He states he tried over the counter topical lotions and oral Benadryl (diphenhydramine) with no relief the itching persists — Denies, cough, fever, pain, night sweats, SOB, chest pain, or upper respiratory symptoms. States he has allergic rhinitis, not an issue now. He states the “rash” is forming blisters that are “getting bigger.” PMH is significant for asthma, eczema, & GERD. Allergic to cats, pollen, mold, minocycline, & sulfa drugs. Medication takes daily is omeprazole, albuterol MDI, fluticasone propionate MDI. Up-to-date on childhood vaccines denies any since graduated from high school. Denies an annual influenza vaccine, tobacco use, & illicit drug use. States ETOH “sometimes” but refuses to elaborate.
What additional historical (subjective) information is needed?
Physical Exam
VS: BP 128/82, HR 64 regular, RR 12, T 98.3, Ht 73 inches, Wt 185 pounds
Gen: well-appearing male in no acute distress
Skin: bilateral forearms pruritic erythematous rash with vesicles arranged in a linear
distribution. No lesion or rash to Les, trunk, GU region or buttocks. No palpable lymph nodes.
HEENT: head: normocephalic no masses or trauma. eyes: PERRLA, EOMs intact, no
scleral or conjunctival injection. Ears: ear canals w/o erythema or irritation, TMs clear,
pearly gray, bony landmarks visible. No discharge or pain. Oropharynx no redness or
discharge. Neck: supple w/o masses or palpable lymph nodes, thyroid nonpalpable, no JVD
CV: S1S2 RRR. No murmur or rubs.
Lungs: CTA
Abdomen: soft NT ND BS x 4 quadrants. No HSM or bruits
Musculoskeletal: Full Range of Motion, BLEs & BUEs no joint swelling, pain or erythema
Sample Solutions
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