CHIEF COMPLAINT: Swelling, rash and itching to both hands.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old female presented to the emergency department this morning complaining of persistent redness, swelling, and itching to both of her hands. She notes a longstanding history of psoriasis.
Apparently, she works as a nurse at a local nursing home. She indicates that she does use latex and powder-free gloves. Noted some increased redness, swelling and itching to both hands over the course of the past week.
She has previously been given cortisone injections for treatment of this swelling; however, she does not currently have a primary care provider and is actually requesting a dermatology referral at this time for treatment of this chronic condition.
She presents now for evaluation and treatment.
REVIEW OF SYSTEMS: The patient denies fever, chills, nausea, vomiting or diarrhea. She denies any upper respiratory symptoms, especially swelling of her lips, tongue or adjacent oral structures. She denies any chest pain, shortness of breath or wheezing. She notes rash, swelling, and itching to both hands. Otherwise, she denies limited range of motion to the same as well as any numbness, tingling or paresthesias to her extremities or muscle weakness. The remainder of review of systems, otherwise, is negative as pertains to chief complaint.
Nursing notes reviewed.
PAST MEDICAL HISTORY: Eczema and psoriasis as well as asthma.
PAST SURGICAL HISTORY: Hysterectomy.
CURRENT THERAPY: None.
ALLERGIES: None.
IMMUNIZATION HISTORY: Not applicable.
SOCIAL HISTORY: The patient is a half-pack-per-day cigarette smoker, notes occasional alcohol consumption, and denies any illicit substance abuse.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 97.4, pulse 106, respirations 18, BP 152/106. Pulse oximetry 99% on room air.
GENERAL: A well-developed, well-nourished, nontoxic, ambulatory (XX)-year-old female.
MENTAL STATUS: The patient is alert and oriented x3.
HEENT: Normocephalic and atraumatic facies. Ears, eyes, nose, throat all within normal limits. Mucous membranes are moist and pink.
NECK: Supple, nontender, no meningismus. Trachea is midline.
LYMPHATICS: The patient exhibits no lymphadenopathy.
CHEST: Examination of the chest reveals equal bilateral breath sounds, clear to auscultation with normal chest wall excursion.
CARDIOVASCULAR: Regular rate and rhythm without murmur, rub or gallop.
ABDOMEN: Benign.
EXTREMITIES: Exam reveals diffuse psoriatic rash to all digits of both hands, including the webbed spaces between the same. She exhibits full range of motion of all extremities without deficit. She exhibits strong distal pulses, brisk capillary refill in all distal extremities.
NEUROLOGIC: Reveals no gross motor/sensory deficits. The patient is alert, cooperative and exhibits intact distal sensation in all extremities.
INTEGUMENTARY: Skin without diaphoresis, rash, lesions with the exception of rash to both hands as noted above. Skin is otherwise warm and dry to touch. Normal tone and turgor.
DIAGNOSTIC DATA: None.
EMERGENCY DEPARTMENT COURSE: The patient has been stable throughout her stay in the emergency department.
MEDICAL DECISION MAKING: We discussed this patient’s case with Dr. John Doe who also evaluated the patient and agreed with the final diagnosis of bilateral hand dermatitis, probable psoriasis and the treatment plan that follows.
CONSULTATIONS: None.
IMPRESSION: Bilateral hand dermatitis, probable psoriasis.
PLAN:
1. Prednisone 50 mg daily for the next 5 days.
2. No latex or powder exposure to skin.
3. Follow up in dermatology clinic for re-evaluation in 5-7 days.
4. Return to the emergency department for any worsening symptoms or new concerns.
The patient voiced agreement with this final diagnosis and treatment plan. She voiced clear understanding of the instructions.
DISPOSITION: Discharged to home in good condition.
