DATE OF SERVICE: MM/DD/YYYY
CHIEF COMPLAINT: Rash.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female who is otherwise healthy presenting to the ER with complaints of a one- to two-week history of pruritic rash. The patient’s other household members had a similar rash. Her grandmother was recently diagnosed with scabies. She has been taking Benadryl and applying an over-the-counter anti-itch cream with no significant improvement. She has had no fevers, chills, URI symptoms, nausea, vomiting, no other systemic symptoms and otherwise has no complaints.
PAST MEDICAL HISTORY: None.
MEDICATIONS: None.
ALLERGIES: None.
FAMILY HISTORY: Not elicited.
SOCIAL HISTORY: The patient is without a family practice for primary care.
REVIEW OF SYSTEMS: As stated above, in the HPI, is significant for pruritic rash with similar contacts. She has otherwise been well without fevers, chills, nausea, vomiting, abdominal pain, changes in urinary or bowel habits, polyuria or polydipsia, heat or cold intolerance, fatigue, recent weight changes. Further review is otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse 92, respirations 18, temperature 98.6, pulse ox on room air is 100%.
GENERAL: This is a well-developed, well-nourished Hispanic female in no acute distress. She is alert and oriented x 3.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact. Mucous membranes are pink and moist.
NECK: Supple.
CHEST: Respirations are easy and unlabored.
LUNGS: Clear to auscultation bilaterally without wheezes, rales, rhonchi.
HEART: Regular rate and rhythm without murmur, rub or gallop.
ABDOMEN: Soft, nondistended, and nontender.
EXTREMITIES: No cyanosis, edema or clubbing.
SKIN: The patient has a diffuse papular rash noted mostly on the trunk but also scattered on the extremities as well with involvement of the finger webs. Several areas are excoriated. There is no evidence of secondary bacterial infection. Skin is otherwise warm, dry, and intact.
EMERGENCY DEPARTMENT COURSE: The patient was discussed with Dr. John Doe who agrees with the assessment and plan.
DIAGNOSIS: Scabies.
PLAN:
1. The patient is given a prescription for Elimite cream to apply as directed. She is to repeat this in one week if necessary.
2. Follow up with her primary care physician if there is no improvement in the next 7 to 10 days.
3. She is given a prescription for Benadryl to take as directed for itching.
4. Mother is encouraged to wash all the clothes and linens in hot water.
DISPOSITION: The patient is discharged home in good condition and ambulated out of the department without difficulty.
