Skin Conditions Assessment

Title
Your Name
Subject and Section
Professor’s Name
Date of Submission
Patient Initials: A.J.Age: 23 y/oGender: FemaleDate of interview: March 23, 2020
SUBJECTIVE DATA:
Chief Complaint (CC): “I have a rash on my arm that hurts so bad, like it is pricking.”
History of Present Illness (HPI):
A.J., is a 23 year-old, female, Roman Catholic, Caucasian patient who presented in the dermatologist’s clinic with a tingling, and sometimes, stabbing sensation on the volar aspect of her right arm graded 6/10 on subjective pain scale, that radiates to her bilateral lower back area. 2 days ago, in the morning, the patient experienced a headache on her bilateral temporal areas (as pointed by the patient) which was followed fever late at night (37.5 deg C) and chills. The next morning the patient felt body pain and weakness that she had a hard time preparing and going to work. Her headache diminished but increased in intensity later in the afternoon. Yesterday, the patient noticed that she had red rashes that looked like chicken pox on the anterior portion of her right arm. She has not consulted right away since it did not bother her that much. That night, the patient suddenly felt stabbing pain that radiated to her back. When she looked at the mirror, she noticed that her back and the volar aspect of her back have the same lesions. She took pain relievers that decreased the pain slightly. Thus, prompting her to have a consult.
Medications:
1 Ibuprofen 200mg orally taken whenever necessary
Allergies:
1 Allergic to all kinds of seafoods
2 The patient denies any other allergies known to her
Past Medical History (PMH):
* The patient had a history of chickenpox in 2010
* Urinary Tract Infection (December 2019)
Surgical History:
Unremarkable
Sexual/Reproductive History:
* The patient is heterosexual, currently sexually active, with one partner. Admits to have 2 previous partners. Uses protection (condom) most of the time, but sometimes, uses the withdrawal method for all of her 3 partners. She became sexually active at the age of 19.
* G0P0
* Menarche: 15 years-old
* LMP: March 3, 2020
* The patient has a regular menstrual period with a 28-32 day cycle monthly.
21907526479500Personal/Social History:
35242571628000Immunization History:
Significant Family History:
There is a history of chronic kidney disease and hypertension on his dad’s side while her mom has diabetes mellitus and had nephrolithiasis in 2005 which was removed by surgery. Her brother who had chicken pox 2 weeks ago visited her in her apartment 1 week ago.
Lifestyle:
The patient works at a local diner in her hometown as a full-time worker with an 8-hour shift; She resides in the countryside, with a low crime rate and good public transportation. She was not yet finished with college but is planning to go back to school. She currently lives alone in a small apartment near the local diner where she worked for. She goes to work using bicycle but sometimes, when in rush, she utilizes the public transport.
The patient has a healthy diet and claims that she is physically active by doing brisk walking.
Review of Systems:
3429005016500
228600188214000HEENT: Sh...