TIME OF VISIT: 1845.
CHIEF COMPLAINT: Bug bites.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female who states, two days ago, she was at a friend’s house when she woke up with multiple bug bites to her left dorsal forearm. She states she has noticed some swelling since then and itching, which has been improved with hydrocortisone cream. The patient denies any other areas of “rashing.” The patient denies itching in the finger webs. The face was spared. The palms and soles were spared. The patient denies any sick contacts. No other household members with similar bites. She denies any pain associated or fever. She, otherwise, has no complaints.
PAST MEDICAL HISTORY: None.
MEDICATIONS: Depo-Provera.
ALLERGIES: NKDA.
FAMILY HISTORY: Not elicited.
SOCIAL HISTORY: The patient is followed at (XX) Clinic.
REVIEW OF SYSTEMS: As stated above in the HPI. Significant for pruritic rash consistent with bug bites to the left upper extremity associated with swelling. She has, otherwise, been well without fevers, chills, nausea, vomiting, difficulty breathing or swelling, polyuria, polydipsia, heat or cold intolerance, fatigue, recent weight changes, changes in urinary or bowel habits. Further review is otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 134/84, pulse 120, respirations 22, temperature 98.6, and pulse ox on room air is 97%
GENERAL: The patient is a moderately obese Hispanic female in no acute distress. She is alert and oriented x3.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact. Mucous membranes are pink and moist. She is handling her secretions well. There is no stridor.
NECK: Supple without lymphadenopathy.
CHEST: Respirations easy and unlabored.
LUNGS: Clear to auscultation bilaterally without wheezes, rales, or rhonchi.
HEART: Regular rate and rhythm without murmur, rub, or gallop.
EXTREMITIES: No cyanosis, edema, or clubbing. Focused examination of the left upper extremity exhibits no gross deformity, ecchymosis, or swelling. Radial and ulnar pulses are present and equal bilaterally with brisk capillary refill in all five digits. Axillary, median, radial, and ulnar nerves are intact. She has full range of motion in all five digits, wrist, elbow, and shoulder.
SKIN: The patient has multiple erythematous papules approximately 0.5 cm in diameter noted on the dorsal forearm, as well as two additional noted on the left posterior shoulder. There are no excoriations. No evidence of warmth or erythema or signs consistent with secondary bacterial infection. There is no burrowing noted. No other areas of rashes. Skin is otherwise warm, dry, and intact.
EMERGENCY DEPARTMENT COURSE: The patient’s repeat pulse was 97. Dr. Jane Doe saw the patient and agrees with the assessment and plan.
DIAGNOSIS: Dermatitis consistent with bug bites. She is currently suffering from a local reaction, however. We cannot rule out scabies. Therefore, she will be treated conservatively.
PLAN:
1. She is to take Atarax as directed for itching. The patient was provided a prescription. She was also prescribed Elimite cream to apply as directed and repeat in one week if necessary.
2. She is to follow up with her primary care physician in three to four days if there is no improvement.
3. Return to the ED for any signs of infection or other worsening symptoms.
DISPOSITION: She was discharged home in good condition and ambulated out of the department without difficulty.
