SUBJECTIVE DATA: Chief Complaint (CC):Small, itchy, raised patches on lower back History of Present Illness (HPI):Jeremiah Jergens is a 54-year-old Caucasian male who presents today with a large cluster of thick, red, raised patches on his lower back.Jeremiah first noticed the patches 4 years ago, a few days after he recovered from a strep throat infection.He has associated symptoms of tenderness, itchiness and flaking of the patches. They often bleed when he accidently scratches off a patch.He reported the he is “embarrassed by the look of it” and will not take his shirt off at the beach.He has also noticed both his knees, joints in his fingers and back are very stiff in the mornings but lessens after walking and using his joints for a bit.He has been using Tylenol to help with the joint pain and for the patches, he reports using Benadryl ointment for the itching.Both provide minimal relief.He rates his discomfort a 4/10 today but in mornings 7/10 due to the joint pain. Medications: 1.Over-the-counter Tylenol 500mg PO once daily in the morning © 2014 Laureate Education, Inc.Page 1 of 7
2.Over-the-counter Benadryl Extra Strength topical ointment as needed 3.Atenolol 75 mg PO twice daily 4.Over-the-counter Aspirin 325 mg PO once daily 5.Men’s Multivitamin once daily 6.Epi-Pen as needed Allergies: 1.Penicillin – rash 2.Salmon – anaphylaxis 3.Peaches – lip itching Past Medical History (PMH): 1.Chicken Pox – age 5 2.Streptococcal Pharyngitis, recurrent– age 50 3.Morbid obesity Past Surgical History (PSH): 1.Gastric bypass surgery – age 52 2.Appendectomy – age 23 3.Tonsillectomy – pt states “I was about 7 years old” 4.Vasectomy – age 32 Sexual/Reproductive History: Heterosexual Vasectomy – age 32 Personal/Social History: He quit smoking 8 months ago after smoking 2.5 packs daily x 31 years; has an occasional beer during social outings; denies any drug use; enjoys hiking, riding
Order this paper