Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Tinea Pedis - H&P
Description: Itchy red rash on feet - Tinea Pedis
(Medical Transcription Sample Report)
CHIEF COMPLAINT (1/1): This 24 year-old female presents today complaining of itchy, red rash on feet. Associated signs and symptoms: Associated signs and symptoms include tingling, right. Context: Patient denies any previous history, related trauma or previous treatments for this condition. Duration: Condition has existed for 4 weeks. Location: She indicates the problem location is right great toe, right 2nd toe, right 3rd toe and right 4th toe. Modifying factors: Patient indicates ice improves condition. Quality: Quality of the itch is described by the patient as constant. Severity: Severity of condition is unbearable. Timing (onset/frequency): Onset was after leaving on sweaty socks.
ALLERGIES: Patient admits allergies to adhesive tape resulting in severe rash.
MEDICATION HISTORY: None.
PAST MEDICAL HISTORY: Childhood Illnesses: (+) chickenpox, (+) frequent ear infections.
PAST SURGICAL HISTORY: Patient admits past surgical history of ear tubes.
SOCIAL HISTORY: Patient admits alcohol use Drinking is described as social, Patient denies tobacco use, Patient denies illegal drug use, Patient denies STD history.
FAMILY HISTORY: Patient admits a family history of cataract associated with maternal grandmother,
headaches/migraines associated with maternal aunt.
REVIEW OF SYSTEMS: Unremarkable with exception of chief complaint.
PHYSICAL EXAM: BP Sitting: 110/64 Resp: 18 HR: 66 Temp: 98.6
Patient is a 24 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus. Cardiovascular: Skin temperature of the lower extremities is warm to cool, proximal to distal.
DP pulses palpable bilateral.
PT pulses palpable bilateral.
No edema observed.
Varicosities are not observed. Skin: Right great toe, right 2nd toe, right 3rd toe and right 4th toenail shows erythema and scaling.
Neurological: Touch, pin, vibratory and proprioception sensations are normal. Deep tendon reflexes normal.
Musculoskeletal: Muscle strength is 5/5 for all groups tested. Muscle tone is normal. Inspection and palpation of bones, joints and muscles is unremarkable.
TEST RESULTS: No tests to report at this time
IMPRESSION: Tinea pedis.
PLAN: Obtained fungal culture of skin from right toes. KOH prep performed revealed no visible microbes.
PRESCRIPTIONS: Lotrimin AF Dosage: 1% cream Sig: apply qid Dispense: 4oz tube Refills: 0 Allow Generic: Yes
Keywords: consult - history and phy., red rash, itchy, feet, rash, tinea pedis, fungal culture, koh prep, rash on feet, tinea, pedis, toe,