CHIEF COMPLAINT (C/C)
“I have mild itching on my scalp. The itchiness began at one focal point but it is spreading to other areas. I feel like I have lost hair in some regions of the scalp. The itchy areas are painful with non-scaly patches due to persistent scratching.”
HISTORY OF PRESENT ILLNESS (HPI)
A 42-year-old white female patient has reported to the clinic complaining of pruritus and diffusing hair loss on the scalp. The pruritus and hair loss have persisted for the past two weeks. As reported by the patient, her symptoms started like a simple scratch on a focal area of the scalp but it has since spread to other areas characterized by hair loss.
She further reports that areas of hair loss have non-scaly patches which do not resolve even by washing. The patient denies using any oral or topical medications to treat her current symptoms. She further indicates that cold weather aggravates the itchiness which is relieved during hot weather. She reports undergoing distress in the past one month due to personal life issues.
PAST HISTORY
CHILDHOOD ILLNESSES:
Does not report a history of chickenpox measles, mumps, rubella, whooping cough, rheumatic fever, scarlet fever, or polio.
IMMUNIZATION:
Childhood vaccine
Immunization
– Hepatitis B: 3/3
– Diphtheria, Tetanus, and Pertussis: 5/5
– Booster dose of TDAP 2018
– Hemophilus influenza type B: 4/4
– Pneumococcal conjugate: 4/4
– Inactivated Polio- virus- 4/4
– Measles, Mumps, Rubella: 2/2
HPV Three dose Series completed 2000
Influenza 12/21
COVID vaccine Completed 11/13/21, 3/15/21. She has not received a booster dose for COVID vaccine.
ADULT ILLNESS: Denies a serious medical condition during adulthood.
PSYCHIATRIC ILLNESS: Denies past or present psychiatric illnesses.
ACCIDENTS or INJURIES: Denies accidents or injuries
OPERATIONS: Reports undergoing operation during child birth at the age of 25 years. The patient reports undergoing a caesarian section when she was giving birth to her twins 17 years ago.
ALLERGIES: No known drug or food allergies.
MEDICATIONS: The patient denies using any medications at the moment.
COMPLIMENTARY TREATMENTS: None
FAMILY HISTORY: Father died of stroke at the age of 76 years. Mother is 66 years old. She is currently alive and was diagnosed with Type 2 diabetes mellitus 5 years ago. Her diabetes is well-controlled. The patient has three brothers aged 37 years, 34 years, and 32 years and one sister aged 20 years. All her siblings are healthy. Both maternal and paternal grandparents are deceased. The causes of their death are unknown.
SOCIAL HISTORY
Education: A university graduate
Occupation: Accountant
Living situation: Lives with her kids in a rental house
Denies a history of childhood asthma. Denies a history of hemoptysis, bronchitis, emphysema, pneumonia, tuberculosis, or pleurisy. Does not report TB or exposure to TB. Last physical check-up for pulmonary function was five years ago. Denies a history of pneumonia or a history of exposure to chemicals.
CARDIAC: Denies chest pain, or palpitations. Denies paroxysmal nocturnal dyspnea. Does not report orthopnea, edema, palpitations, hypertension, or known heart disease. Denies rheumatic fever, heart murmurs, or pain in posterior calves.
GASTROINTESTINAL: Denies abdominal pain, trouble swallowing, heartburn, problem with appetite, nausea, vomiting, regurgitation, vomiting of blood, indigestion, food intolerance, excessive belching, burping, or passing of gas; denies constipation, diarrhea, jaundice, liver or gallbladder trouble, hepatitis. Reports soft brown stool with bowel movements occurring 1-2 times daily.
PHYSICAL EXAMINATION
VITAL SIGNS: BP: 117/73 (sitting, automatic), P: 98, RR: 20, T: 37.6 Ht: 58 inches Wt: 154 lbs; BMI: 24.3 (the patient indicates that this ranges within her usual weight).
GENERAL SURVEY: Alert and oriented to time, person, and place. Evidence of acute distress and fatigue. Well nourished. The patient’s appearance is appropriate for the stated age.
SKIN: Skin is smooth, warm, dry, and intact without rashes, or lesions. Nail beds are pink with no evidence of clubbing or cyanosis.
HEAD: The head is normocephalic and atraumatic. Hair is short. There is evidence of hair loss in some areas of the scalp. Areas of hair loss appear non-scaly. There is also evidence of hair thinning and broken hair shafts in the regions that surround regions of hair loss on the scalp. There is uneven distribution of hair on the scalp. The remaining hair is black in color. Hair texture is soft. The