4 – Derm | CLINIBORG

HISTORY:
provided by patient SO/family member present during visit chaperon/MA present during visit interpretation provided by family member/SO interpretation provided by MA complete history unobtainable d/t poor effort/affect complete history unobtainable d/t cognitive changes or lack of knowledge complete history unobtainable d/t language skills

CC:
redness rash skin lesion tender area swollen area possible insect bite suspicious mole acne

LOCATION: left right upper lower first second third fourth fifth proximal distal medial lateral dorsal ventral midline

QUALITY:
itchy painful burning oozing painless

STATED CAUSE:
contact exposure new medication possible food-borne insect bite associated with infectious illness new topical medication new oral medication trauma sexual exposure surgical procedure unknown

HPI:
no similar sx previously similar sx previously started just prior to arrival started today started yesterday started days ago started months ago sx increasing in severity sx persist sx decreasing in severity spreading taking OTC, not helping taking ABX, not helping taking OC, not helping taking spironalactone, not helping not taking any medications

TETANUS:
up to date less than five years ago 5-10 years ago greater than 10 years ago unknown
RECENT HISTORY:

[+] reported [-] not reported
PCP visit ER/UC visit hospitalization travel ID exposure surgery/procedure
PMSH:
reviewed sick contact school travel surgery

REVIEW OF SYSTEMS:
[+] reported [-] not reported
negative except as stated in HPI
CONSTITUTIONAL:

objective fever subjective fever chills fatigue weight loss
EYES:

decrease in vision photophobia redness/irritation discharge lid swelling
EARS:

pain pressure discharge wax
NOSE:

discharge PND congestion sinus pressure bleeding
MOUTH:

sores tongue pain/swelling toothache
THROAT:

sore throat odynophagia dysphagia hoarseness
NECK:

pain stiffness swelling swollen glands
CV:

chest pain/pressure SOB palpitations ankle swelling ankle discoloration varicose veins leg cramps
CHEST/RESPIRATORY:

chest tightness rib pain cough
GI:

nausea vomiting bloating heartburn gas abdominal pain constipation diarrhea
GU:

dysuria retention incontinence genital lesion/discharge
MSK:

neck/back pain chronic pain/meds localized joint pain/deformity generalized joint pain localized muscle/soft tissue pain/swelling myalgias
NEURO:

dizziness poor balance abnormality of walk focal weakness blackouts seizures tingling/numbness
PSYCH:

irritability confusion depression anxiety mood swings memory loss insomnia
LYMPH/HEMA:

gland swelling bruising anticoagulation DVT/clotting anemia
ALLERGIES/IMMUNE:

atopy food allergies autoimmune dz h/o cancer

Appearance:
well-appearing alert non-toxic normal WOB allows exam crying but consolable ill-appearing tired-looking diaphoretic poor cooperation with exam drowsy appears impaired slumped

Skin:
warm, dry normal turgor tattoos body piercings pallor cyanosis poor turgor diaphoresis

Head/Face:
normocephalic, atraumatic no facial tenderness symmetrical face CN grossly intact

Eyes:
clear conjunctiva w/o exudates or hemorrhage, EOM intact without nystagmus visual acuity grossly intact corneas clear wears glasses wears contacts conjunctival injection epiphora conjunctival exudate allergic shiners dennie lines palpebral edema/exudates

Ears:
symmetrical & intact auricles bilaterally hearing to conversation intact clear canals without erythema or discharge TMs normal in appearance tragal tenderness swelling of external auditory canal pustule in canal cerumen in canal TM obscured by cerumen HOH hearing aid(s) TM red pus/fluid behind TM TM bulging

Nose:
nares patent bilaterally septum midline mucosa pink & moist allergic salute deviated septum mucosal edema clear discharge purulent nasal drainage

Mouth:
tongue normal in appearance w/o lesions and with good symmetrical movements moist oral mucosa without lesions upper denture lower denture oral ulcers gum swelling tooth decay

Throat:
normal voice patent pharynx w/o swelling or exudates hoarseness pharyngeal erythema w/o exudates

Neck:
symmetric with free painless ROM no LAD anterior LAD posterior LAD nuchal tenderness

Chest/Lungs:
normal work of breathing, symmetrical chest expansion no retractions clear and equal breath sounds bilaterally chest wall atraumatic and non-tender no axillary or supraclavicular LAD SOB decreased breath sounds expiratory wheezing crackles poor effort

CV:
regular rhythm no murmurs no ankle edema pedal skin warm with good & equal pulses tachycardia irregular heart rhythm systolic murmur calf tenderness ankle edema varicosities stasis discoloration

Abdomen:
not examined normal visual inspection, no distension normal active bowel sounds soft non-tender protruding surgical scar umbilical hernia diffuse tenderness over entire abdomen w/o RRG

GU:
not examined no suprapubic tenderness no CVAT bilaterally normal external genitalia no inguinal LAD no urethral discharge

MSK:
no gross deformities, moves all extremities with good ROM for age full weight-bearing normal curvature & ROM in C- & L-spine for patient’s age

Neuro:
normal concentration and attention memory grossly intact balance & coordination grossly intact normal speech no gross motor deficits sensation symmetrical & grossly intact extremities strong w/o atrophy, tremor or fasciculations antalgic gait wide gait shuffling gait

Behavior:
calm pleasant respectful cooperative with exam poor cooperation with exam guarded anxious fearful suspicious hypervigilant irritable frustrated restless labile sighing crying agitated raising voice defensive argumentative hostile forceful intense euphoric insisting on particular medication, test, referral, or accommodation withdrawn indifferent appears to be responding to internal psychotic process

Psychomotor Activity:
no involuntary movements tremor tardive dyskinesia tics bradykinetic fidgeting picking skin twirling hair cracking knuckles threatening posture/movement grimacing, furrowing eyebrows tightening jaw breathing hard shaking extremities clenching fists intense staring standing up and/or pacing opening door to hallway exited exam room during exam

Speech/Vocalization:
age-appropriate clear & coherent normal rate & rhythm slurred monotonous stuttering hypoverbal hyperverbal loud soft slow rapid pressured repetitive questions cursing, swearing criticisms of staff verbal threats

Lesion:
single lesion multiple discrete lesions multiple grouped lesions symmetrical unilateral macular patch papular plaque maculopapular follicular urticarial targetoid vesicular pustular erythema rash purpura wheel/hives swelling nodule/mass abscess burn scar erosion desquamation burrow fissure firm soft warm tender oozing deep mobile pointing fluctuant painful linear annular arcuate serpiginous reticular red hyperpigmented hypopigmented purpuric/non-blanching blanching uniform color several colors smooth sandpaper-like crusty scaly sharply-demarcated borders indistinct borders with surrounding erythema with surrounding induration with lymphangitis with satellites

OFFICE DIAGNOSTICS:
none

DX:
pityriasis rosea
drug rash
contact dermatitis
eczema
rosacea
erythema multiforme
hives
impetigo
streptococcal associated rash
acne
hidradenitis suppurativa
insect bite(s)
scabies
herpes zoster
psoriasis
cellulitis
sebaceous cyst
pilonidal cyst

A/P:

PLAN OF CARE:
POC risks/benefits/alternatives discussed with patient/parent/SO, opportunity provided to ask questions verbalized understanding of and agreement with POC, discharge & f/u instructions did not agree with my POC/recommendations – will seek second opinion/further care elsewhere

RX:
none electronic paper given to MA to be transmitted to pharmacy

LABS:
none CBC CMP UA STI UDS throat cx skin cx

REFERRALS:
none dermatology

REVIEWED:
MA notes med list previous visits/results specialty reports hospital discharge

INSTRUCTED ON:
vital signs/exam findings/recommendations appropriate follow up reporting medication side effects immediately laboratory/diagnostic studies specialty consults

FOLLOW UP:
RTC as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx, PRN 24 hours 48 hours 72 hours 1 week

BARRIERS TO CARE:
none identified poor cooperation with exam lack of motivation negative attitude to diagnostic impression & proposed tx incomplete history vague shifting complaints history not supported by objective findings poor compliance with POC multiple comorbidities polypharmacy lack of interest in nonpharmacologic therapies overwhelming focus on Rx drugs intolerance of multiple meds frequent ER/UC visits altered mental status hostile/disruptive behavior active psychiatric diagnosis alcohol or substance use social/cultural barriers victim of abuse perseveration flight of ideas preoccupation with illness catastrophization overgeneralization unrealistic beliefs negativism pessimism blaming others staff splitting

DISPOSITION:
home referred to ER for immediate treatment via 911 referred to ER for immediate treatment via private transport declined emergency transfer left facility before being discharged asked to leave clinic

4 – Derm

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