CC: Pt feels “anxious about itchy and red rash” all over her body

HPI:
19 y/o female with a history of frequent UTIs. She began experiencing symptoms a few days ago that were similar to those of her previous UTIs. She went to her PCP and was prescribed sulfamethoxazole – trimethoprim DS 1 tablet twice/day. Today was the third day of taking the medication and she woke up and experiencing a “rash all over her body”. Her skin feels extremely itchy and she describes it as red. She tried lotion and diphenhydramine with no relief. She is very anxious about the rash. She says she feels like she has a fever but has no chills. She feels very tired and her throat feels scratchy. She does not have any associated headache, eye pain, vision changes, ear pain or loss of hearing. She is not experiencing any chest pain, palpations, SOB, cough, nausea, vomiting, or diarrhea.

Histories (Hx): Meds and Allergies: sulfamethoxazole – trimethoprim DS t tablet 2x/day for UTI symptoms, NKDA. I would ask “Are you taking any vitamins or supplements?”

Med Hx: Frequent UTIs; pt previously had heavy periods and bad cramping which has resolved over the last 2 years

Surgical Hx: none

Family Hx: Mother and father are in good health. No siblings. I would ask “Do your mother’s parents have any health conditions?” If there is a history of an illness, I would ask “What was the age that he/she was diagnosed?” I would also ask “Do you father’s parents have any health conditions?” If there is a history of an illness, I would ask “What was the age that he/she was diagnosed?”

Social Hx: Patient is in college. She has one roommate, Zelda. She is sexually active with her boyfriend, Gary, and they use condoms. She feels safe in her living situation and environments. I would ask “Have you had any recent travel?”

T/A/D (tobacco, alcohol, and drugs): denies tobacco use, denies drug use, drinks alcohol occasionally, not more than 3 drinks/night

Health Promotion: Pt exercises 5-6 days/week, usually jogging or bike riding. She eats a mostly vegetarian diet, usually only eating meat on holidays or special occasions.

ROS (review of systems) General: no chills, pt feels like she has a fever. Pt feels very tired. I would ask “Have you gained or lost a lot of weight recently without trying?”

Skin: itchy rash all over the body that is red, very irritating to the pt. I would ask “Any moles that have changed recently or do you have any changes in your hair or nails?”

HEENT: no headache, no dizziness, and does not feel faint. She has no eye pain, no changes in vision, no ear pain or loss of hearing. I would ask “Do you have a stuffy or runny nose?” Her throat is scratchy.

Cardiac: no chest pain, SOB, or palpitations

Respiratory: no SOB or cough

GI: no nausea, vomiting, or diarrhea. I would ask “Have you noticed any changes in your bowels or stools?”

Musculoskeletal: I would ask “Have you had any recent muscle cramps, muscle weakness or stiffness in your joints?”

Breast: I would ask “Have you noticed any lumps, tenderness, or discharge from her nipples? Any areas of color change on your breast?”

Neurological/Psych: feels anxious about the rash, no numbness or tingling, no dizziness and does not feel faint. I would ask “Have you had any falls? Any mood changes?”

GU: I would ask “Any changes in the amount of times that you go to the bathroom in a day? Any pain when you urinate? Any blood in your urine? Any pain in your lower back or sides?”

Endocrine: I would ask “Do you have frequent thirst? Have you had any changes in your appetite? Have you noticed any heat or cold intolerance?”

Hematologic/Lymphatic: I would ask “Do you bruise easily? Do you bleed easily if you have a cut?”

Genitalia: no pregnancies or births. Regular period every 28 days that typically lasts 3 -4 days. Pt previously had heavy periods and bad cramping which has resolved over the last 2 years

PE (Physical Exam) Vital Signs: BP 110/65, HR 122, RR 24, Temp 99.6 F, Wt 135 lbs, Ht 5’8”, BMI 20.5

General: Generally a well-developed, physically fit, adolescent female sitting on bed. HEENT: Eyes: PERRLA, EOM intact; Ears: External ears normal, no lesions or deformities. Hearing intact bilaterally; Nose: external nose normal, no lesions or deformities; nasal mucosa, septum, and turbinates normal; good dentition, normal tongue, posterior pharynx without erythema or exudates. Neck is supple, no masses, trachea midline; no thyroid nodules, masses, tenderness, or enlargement Cardiac: S1, S2, normal rhythm, no murmurs, rub or gallop; no thrill or palpable murmurs on palpation, no JVD, no carotid or abdominal bruits; no enlargement of aorta. Carotid, radial, posterior tibias, and pedal pulses 2+ symmetric, no edema Respiratory: Clear or auscultation bilaterally, normal tactile fremitus, no egohony, normal respiratory effort with no use of accessory muscles

GI: soft, non-tender, and non-distended abdomen with no masses; bowels sounds active, no liver nodularity or masses, no splenomegaly

Musculoskeletal: normal alignment, mobility, and no deformity of head and neck, spine, ribs, pelvis; normal ROM and normal strength in all extremities, no joint enlargement or tenderness, no clubbing, cyanosis, or nodes of digits and nails

Skin: acute red urticaria all over the body

Neurological: cranial nerves II-XII intact, 2+, symmetric, reflexes, intact to touch, pin, vibration, and position in lower extremities; normal finger-to-nose,

GU: external genitalia is w/out lesions, introitus is normal, vagina walls pink and moist w/out lesions or evidence or trauma

Psych: appropriate affect, judgment and insight intact

Hematologic/Lymphatic: no bruises, no cervical, clavicular, subcutaneous auricular lymphadenopathy

A/P (assessment and plan):

1. Dx: drug eruption – most likely from the antibiotic prescribed
a. Advise pt about self-care and to take rest
b. Have pt stop taking the antibiotics currently prescribed and request a new antibiotic prescription
2. Dx: Mononucleosis – most likely from boyfriend
a. Advise pt about self-care and to take rest
b. Request blood test to rule out Mono
3. Dx: Dengue fever
a. Advise pt about self-care and to take rest
b. DENV Detect IgM Capture ELISA

Nursing Diagnoses:
1. Impaired skin integrity r/t rash aeb erythema and pt scratching herself
2. Impaired comfort r/t rash aeb pt stating that skin “itches horribly”
3. Anxiety r/t rash all over patient’s body aeb by pt stating “I feel anxious about this rash”

Health Maintenance: go to: http://www.uspreventiveservicestaskforce.org/Page/Name/tools-and-resources-for-better-preventive-care and list all the A and B level recommendations for your patient.

A Chlamydia: Screening -- Women Ages 24 and Younger OR Women Ages 25 and Older at Increased Risk
A* Folic Acid: Supplementation -- All Women Planning or Capable of Pregnancy
A* HIV: Screening - Adolescents and Adults
A* High Blood Pressure: Screening -- Adults 18 and Over
A Syphilis: Screening -- Men and Women at Increased Risk
B* Alcohol Misuse: Screening and Behavioral Counseling Interventions in Primary Care -- Adults
B* Depression: Screening -- Adults age 18 and over -- When staff-assisted depression care supports are in place
B Gonorrhea: Screening -- Pregnant Women and Women at Increased Risk
B* Hepatitis B: Screening -- Nonpregnant Adolescents and Adults At High Risk
B* Hepatitis C Virus Infection: Screening--Adults at High Risk and Adults born between 1945 and 1965
B* Intimate Partner Violence: Screening -- Women Childbearing Age
B* Obesity: Screening for and Management of-- All Adults
B* Sexually Transmitted Infections: Behavioral Counseling -- Sexually Active Adolescents and Adults at Increased Risk
B* Skin Cancer: Behavioral Counseling -- Children, Adolescents, and Young Adults aged 10 to 24

Follow-up: (when they should return to the clinic or see PCP)

She should f/u with her PCP or return to the clinic if her rash does not improve over the next few days or if it worsens. If she has difficulty breathing, she should go to the ER immediately.