EXAMPLE #3: Patient with Skin Outbreak |
Subjective:Patient V.H. is a 60 y/o black male who presented to the urgent care clinic with c/o rash lasting >1 wk. He reports the rash first appeared on his lower back toward the spine but has since spread to the abdomen on his right side. Denies experiencing pain when the rash first appeared but now feels pain described as a "burning sensation." He reports increased pain when clothing touches the affected area and, therefore, does not wear a shirt at home. V.H. has been taking APAP 500 mg. q4-6 hours for pain with little relief. He currently rates pain as a 6 on a 1-10 scale. History of HTN and BLE edema. Takes Metoprolol 50 mg. BID and Lasix 20 mg q am.Objective:V.H. is A&O x4 and appears in no acute distress, despite reports of pain. VS: BP 126/78, P 70, R 14, T 98.6 SaO2 98%; Erythematous rash consisting of clustered vesicles beginning on the right lateral spine area and extending around the right flank and abdomen. Some vesicles are fluid-filled, and others are covered with a honey-colored crust.Assessment:Onset of painful rash beginning 1 wk. ago with right lateral distribution. The presence of erythematous, fluid-filled vesicles and honey-colored crusts, distribution, and burning pain suggests herpes zoster. Although cellulitis may be possible, the absence of fever suggests otherwise.Plan:Pt. Will continue using APAP for pain relief, educated patient that symptoms may continue after the rash resolves but that once all lesions have developed crusts, he is no longer contagious. V.H. will return to clinic if pain worsens, fever develops, or lesions do not resolve within 4 weeks. Instructed on importance of keeping open or draining sores loosely covered and to leave scabs and blisters undisturbed. |
