DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Rash.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male who presents complaining of rash. He has a history of urticaria from unknown etiology, approximately eight months ago, and he was seen in the emergency department. He was given prednisone, H1 and H2 blockers, as well as given an EpiPen to go home with. He says that today he was at his friend’s house, and when he was driving home, he started feeling a sensation of itchiness on his neck and chest, and he started noticing welts in this area. He denied any shortness of breath, but per his mother, the patient did have some audible wheezing. The patient was given his EpiPen, and his rash began to improve. He was also given Benadryl and Pepcid at home. Upon arrival to the emergency department, the patient stated the rash was still present, but he had no shortness of breath.
PAST MEDICAL AND SURGICAL HISTORY: History of asthma.
ALLERGIES: No known drug allergies.
MEDICATIONS: Albuterol and EpiPen.
FAMILY HISTORY: Unremarkable.
SOCIAL HISTORY: The patient denies tobacco, ETOH or illicit drug use.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: The patient denies fevers, chills, dizziness, weakness.
CARDIOVASCULAR: The patient denies chest pain, palpitation.
RESPIRATORY: The patient denies shortness of breath, cough.
All other systems negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 108/66, pulse 66, respiratory rate 18, and oxygen saturation 96% on room air.
GENERAL: The patient is a well-developed, well-nourished Hispanic male not in acute distress. Appears comfortable, lying in bed.
LUNGS: Clear bilaterally. No wheezes, rales, rhonchi noted.
HEENT: Oropharynx moist and pink without erythema or exudate. No sublingual swelling, no subglottic swelling.
SKIN: The patient has an erythematous rash present over his chest and extremities. It is blanching. There is dermatographia present. Rash is macular, erythematous, and confluent in some areas.
EMERGENCY DEPARTMENT COURSE: The patient was given 60 mg of prednisone p.o. He was observed in the emergency department. He had no worsening of rash.
MEDICAL DECISION MAKING: This is a patient who presents complaining of an urticarial rash. It is unclear as to the stimulus. He does not appear to have any signs of angioedema, so we do not believe this is a C1 esterase deficiency. As for the etiology of the patient’s symptoms, it is unclear as to the source. He was treated partially by his family with H1, H2 blockers. He was given steroids and placed on steroid taper. The patient will be referred to an allergist for further allergy testing.
DIAGNOSIS: Urticaria.
PLAN:
1. The patient was given prescription for prednisone taper.
2. The patient was given a prescription for EpiPen, since he used his.
3. The patient was instructed to follow up with an allergist.
DISPOSITION: The patient was discharged to home in good condition.
