Armpit Rash ER Sample Report
DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Rash in the armpit.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male brought to the emergency department by his father with a one-week history of a pruritic rash that is confined to his axillary region. The patient has not had any associated fever, chills, nausea, vomiting or diarrhea. He has no complaints of sore throat, chest congestion or trouble breathing.
The patient’s father was unaware of the patient coming in contact with anything that could have caused the rash. He said they are using the same soaps and laundry detergents that they always do.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: None.
MEDICATIONS: None.
ALLERGIES: NKDA.
SOCIAL HISTORY: The patient lives with his father. Negative for exposure to secondary cigarette smoke.
FAMILY HISTORY: Positive for diabetes.
IMMUNIZATION/TETANUS: Up-to-date.
REVIEW OF SYSTEMS: All other systems reviewed and negative.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: The patient was alert and in no apparent distress. He was pleasant and cooperative.
VITAL SIGNS: Blood pressure 82/32, pulse 96, respirations 20, and temperature 97.2.
SKIN: Negative for petechial or purpuric lesions. There was a mildly irritated erythematous raised rash in both axillary regions. The rash was dry.
HEENT: Pupils were equally round and reactive to light. Extraocular muscles are intact. Sclerae nonicteric. Tympanic membranes were normal color bilaterally with good landmarks. Throat: Posterior pharynx was clear. Uvula was midline. Negative for exudate. Mucosa was moist.
NECK: Supple without meningeal signs. Trachea was midline. Negative for JVD.
CHEST: Symmetrical chest expansion was present with adequate air movement. Lung fields were resonant to percussion and clear to auscultation. Negative for use of the accessory muscles.
HEART: S1 and S2 were normal without murmurs, gallops or rubs.
ABDOMEN: Soft and nontender without guarding or rebound tenderness. Negative for hepatosplenomegaly and CVA tenderness.
EXTREMITIES: No cyanosis, edema or tenderness was noted.
NEUROLOGIC: Negative for focal deficits.
Pulse oximetry on room air 99%, which was normal.
IMPRESSION: Contact dermatitis.
PLAN:
1. Triamcinolone cream 0.1% applied to the affected area b.i.d. x5-7 days.
2. The patient’s father was given contact dermatitis instructions. We recommended that they use a mild soap and a mild laundry detergent.
3. Advised the patient’s father that the patient needs to return to the department if his symptoms worsen and that he should follow with his pediatrician in two days.
4. The patient indicated he understood and agreed with the above instructions.
