MRweek 2 discussion

*Subjective

CC: chief complaint – "I have a rash that will not go away, and it is spreading."

HPI: history of present illness –40-year-old male presents today with a rash that he first noticed two months ago. He states the rash started on his chest, but over the last three weeks it has spread to his back and both arms. The patient says that the rash is dry, but not itchy. He denies any pain associated with the rash. The patient states that there is nothing that aggravates the rash. The patient has tried over the counter creams and lotions with no resolution. The patient is concerned that the rash has been there for two months and is beginning to get worse.

PMH: past medical history – Hypoglycemia - 2010 Allergies: NKDA Medications:

The patient is on no routine medications. States occasional use of OTC NSAIDs if has minor pain.

Social history:

Married

Current smoker: pack/day

Alcohol: 6 pack beer daily

Recreational or chemical drug use: Denies Exercise: None

Seatbelt use 50% of the time Sun Exposure frequent Family history:

Father Deceased, Cardiac issues

Mother Deceased, Cardiac issues, MI

Paternal grandmother HTN, Cardiac 78 Paternal grandfather Deceased Stroke 58 Maternal grandmother Diabetic type 2 age 75 Health Maintenance/Promotion:

Wellness Adult Exam/DOT physical

Flu vaccine (current year)

TD (2015)

Exercise - none

Seatbelt 50% of the time

Review of Systems (ROS):

General: Denies, fatigue, fever, and night sweats. Denies anorexia, malaise, weight loss, weight gain, and sleep problems

Skin: Complains of a dry rash to back, chest, and both arms that seem to be spreading, denies other problems

HEENT: Denies blurred vision, double vision, halo, light sensitivity, eye irritation eye discharge, and eye pain. Denies ringing in the ears, ear discharge, earache, nosebleeds, difficulties swallowing. Denies hoarseness and sore throat

Neck: Denies difficulty swallowing, pain with movement or decreased range of motion

CV: Denies chest pain or discomfort, racing/skipping heartbeats or palpitations, lightheadedness, near fainting, fainting, shortness of breath with exertion, difficulty breathing while lying down and leg cramps with exertion

Lungs: Denies shortness of breath at rest, shortness of breath with activity, sleep problems related to breathing, wheezing, excessive sputum, coughing up blood and excessive snoring

GI: Denies indigestion, loss of appetite, nausea, vomiting, abdominal pain, bloating, gas, change in BMs, diarrhea, constipation, blood with BMs

GU: Denies frequency, pain with urination, blood in urine, urinary incontinence or leaking, difficulty starting the urinary stream, difficulty emptying the bladder, nighttime urination.

PV: Denies swelling, leg cramps, coldness of extremeties

MSK: Denies weakness, swelling, joint pain or stiffness, back pain, neck pain, muscle cramps, muscle stiffness

Neuro: Denies numbness and tingling, seizures, stroke, headache, tremors, memory loss or dizziness Endo: Denies heat or cold intolerance, excessive thirst or excessive hunger

Psych: Denies trouble concentrating, nervousness, anxiety, panic attacks, mood changes, hearing voices, feeling unhappy, desire to harm self/others, sleep troubles, nightmares, memory loss, feeling stressed

*Objective:

Physical Examination

VS:

Weight 197

Height 74.5 in

BMI 25.05 BP 130/86

Temp 98.9

PR 70

RR 18

Gen: On physical exam, the patient is alert and oriented in no acute distress.

Skin and hair: Hyperpigmented fine scaly macules that cover bilateral arms, anterior and posterior trunk. Edges are well defined, macules overlap.

HEENT:

Head: Symmetrically round, no lesions or bumps noted Face is oval and symmetrical

Eyes: No redness, discharge, or crusting noted to eyelids, Conjunctiva, and sclera are moist and smooth. The sclera is white with no lesions or redness. Eyes are symmetrical.

Ears: Equal in size bilaterally. Skin is smooth, no lumps, lesions, or nodules noted. No drainage noted non-tender on palpation.

Nose: No deformity, discharge, inflammation, or lesions

Throat/Mouth: No deformity or lesions with good dentitions. Lips are moist and pink. The tongue is midline, moist and pink with normal movement

Neck: The neck is symmetrical with a centered head position and no bulging masses. The thyroid gland is nonvisible. The trachea is midline. No difficulty swallowing.

CV: Regular rate and rhythm. Apical pulse 70. No JVD noted

Lungs: Respirations 18/minute, relaxed, and even. Chest expansion symmetric. No pain or tenderness on palpation. Lung sounds are clear in all lung fields.

Abd: The umbilicus is midline with no bulging noted. The abdomen is flat and symmetric. No pain or tenderness on palpation. No guarding. Bowel tones are active in all four quadrants.

GU: No complaints patient reports voiding without difficulties

PV: No edema noted. No clubbing of fingers or toes. Capillary refill is less than 3 seconds. Skin is warm. Pulses strong and equal. No visible varicosities noted.

MSK: Full ROM in both arms and legs. No weakness noted. Gait is smooth and steady. Extremities are symmetrical

Neuro: PERRLA, no tremors noted. The patient is alert and oriented

Psych: Alert and cooperative, appropriate mood for interaction

Diagnostics: KOH prep obtained and shows fungal spores.

*Assessment:

Diagnosis

1. Tinea Versicolor B36.0

2. Alcohol abuse F10.10

*Plan:

1. Diagnostics: none additional

Therapeutic: Ketoconazole 2% external shampoo apply to dampened affected skin, lathered left on for 5 min then rinse. Apply once daily for three days. Dispense one bottle with one refill.

Educational: The patient was educated on the importance of using shampoo as prescribed. The patient was instructed to follow up if the symptoms do not improve or if it gets worse.

Consultation/Collaboration: N/A

2. Diagnostics: N/A

Therapeutic: N/A

Educational: The patient was educated on the dangers of drinking while taking medication. The patient was educated on the possible effects on his liver. The patient was counseled on how to safely reduce alcohol consumption, if desired, over time – instructed not to quit cold turkey.

Consultation/Collaboration: Quality Behavior Health