*Subjective
CC: chief criticism – “I dangle a rash that is now no longer lunge away, and it’s spreading.”
HPI: historical past of original sickness –40-year-extinct male offers on the present time with a rash that he first seen two months within the past. He states the rash started on his chest, nonetheless over the closing three weeks it has unfold to his reduction and both fingers. The patient says that the rash is dry, nonetheless now no longer itchy. He denies any agonize linked to the rash. The patient states that there’s nothing that aggravates the rash. The patient has tried over-the-counter creams and lotions with out a probability. The patient is anxious that the rash has been there for 2 months and is starting to worsen.
PMH: past scientific historical past – Hypoglycemia – 2010 Hypersensitive reaction symptoms: NKDA Medications:
The patient is on no routine drugs. States occasional use of OTC NSAIDs if has minor agonize.
Social historical past:
Married
Contemporary smoker: pack/day
Alcohol: 6 pack beer every day
Recreational or chemical drug use: Denies Instruct: None
Seatbelt use 50% of the time Solar Publicity frequent Family historical past:
Father Deceased, Cardiac disorders
Mom Deceased, Cardiac disorders, MI
Paternal grandmother HTN, Cardiac 78 Paternal grandfather Deceased Stroke 58 Maternal grandmother Diabetic kind 2 age 75 Health Maintenance/Promotion:
Wellness Adult Examination/DOT physical
Flu vaccine (contemporary year)
TD (2015)
Instruct – none
Seatbelt 50% of the time
Overview of Programs (ROS):
General: Denies, fatigue, fever, and night sweats. Denies anorexia, malaise, weight reduction, weight be triumphant in, and sleep problems
Skin: Complains of a dry rash to reduction, chest, and both fingers that seem to be spreading, denies other problems
HEENT: Denies blurred vision, double vision, halo, light sensitivity, witness irritation witness discharge, and witness agonize. Denies ringing within the ears, ear discharge, earache, nosebleeds, difficulties swallowing. Denies hoarseness and sore throat
Neck: Denies mission swallowing, agonize with movement or lowered fluctuate of movement
CV: Denies chest agonize or discomfort, racing/skipping heartbeats or palpitations, lightheadedness, scheme fainting, fainting, shortness of breath with peril, mission breathing while lying down and leg cramps with peril
Lungs: Denies shortness of breath at leisure, shortness of breath with activity, sleep problems linked to breathing, wheezing, outrageous sputum, coughing up blood and outrageous loud night breathing
GI: Denies indigestion, loss of appetite, nausea, vomiting, belly agonize, bloating, gas, replace in BMs, diarrhea, constipation, blood with BMs
GU: Denies frequency, agonize with urination, blood in urine, urinary incontinence or leaking, mission starting the urinary movement, mission emptying the bladder, center of the night urination.
PV: Denies swelling, leg cramps, coldness of extremeties
MSK: Denies weakness, swelling, joint agonize or stiffness, reduction agonize, neck agonize, muscle cramps, muscle stiffness
Neuro: Denies numbness and tingling, seizures, stroke, headache, tremors, memory loss or dizziness Endo: Denies heat or frigid intolerance, outrageous thirst or outrageous hunger
Psych: Denies agonize concentrating, anxiety, dread, horror attacks, temper adjustments, hearing voices, feeling unhappy, desire to agonize self/others, sleep troubles, nightmares, memory loss, feeling pressured
*Aim:
Physical Examination
VS:
Weight 197
Top 74.5 in
BMI 25.05 BP 130/86
Temp 98.9
PR 70
RR 18
Gen: On physical examination, the patient is alert and oriented in no acute hurt.
Skin and hair: Hyperpigmented ravishing scaly macules that masks bilateral fingers, anterior and posterior trunk. Edges are effectively outlined, macules overlap.
HEENT:
Head: Symmetrically spherical, no lesions or bumps renowned Face is oval and symmetrical
Eyes: No redness, discharge, or crusting renowned to eyelids, Conjunctiva, and sclera are moist and tender. The sclera is white with out a lesions or redness. Eyes are symmetrical.
Ears: Equal in dimension bilaterally. Skin is tender, no lumps, lesions, or nodules renowned. No drainage renowned non-soft on palpation.
Nostril: No deformity, discharge, inflammation, or lesions
Throat/Mouth: No deformity or lesions with suitable dentitions. Lips are moist and purple. The tongue is midline, moist and purple with frequent movement
Neck: The neck is symmetrical with a centered head space and no bulging plenty. The thyroid gland is nonvisible. The trachea is midline. No mission swallowing.
CV: Regular fee and rhythm. Apical pulse 70. No JVD renowned
Lungs: Respirations 18/minute, relaxed, and even. Chest enlargement symmetric. No agonize or tenderness on palpation. Lung sounds are definite in all lung fields.
Abd: The umbilicus is midline with out a bulging renowned. The abdomen is flat and symmetric. No agonize or tenderness on palpation. No guarding. Bowel tones are active in all four quadrants.
GU: No complaints patient experiences voiding with out difficulties
PV: No edema renowned. No clubbing of fingers or toes. Capillary stock up is lower than 3 seconds. Skin is warm. Pulses solid and equal. No seen varicosities renowned.
MSK: Stout ROM in both fingers and legs. No weakness renowned. Gait is tender and celebrated. Extremities are symmetrical
Neuro: PERRLA, no tremors renowned. The patient is alert and oriented
Psych: Alert and cooperative, acceptable temper for interaction
Diagnostics: KOH prep obtained and shows fungal spores.
*Analysis:
Prognosis
1. Tinea Versicolor B36.0
2. Alcohol abuse F10.10
*Conception:
1. Diagnostics: none additional
Therapeutic: Ketoconazole 2% external shampoo phrase to dampened affected pores and skin, lathered left on for five min then rinse. Practice once every day for 3 days. Dispense one bottle with one stock up.
Academic: The patient used to be educated on the importance of using shampoo as prescribed. The patient used to be suggested to apply up if the symptoms develop now no longer toughen or if it will get worse.
Session/Collaboration: N/A
2. Diagnostics: N/A
Therapeutic: N/A
Academic: The patient used to be educated on the dangers of ingesting while taking remedy. The patient used to be educated on the which that you can imagine outcomes on his liver. The patient used to be counseled on how to soundly decrease alcohol consumption, if desired, over time – suggested now no longer to stop frigid turkey.
Session/Collaboration: Quality Habits Health
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