SKIN ASSESSMENT
LAB
Patient: MR
Age: 28
Gender: Male
S:
CC: “I have a rash on my back”
HPI: Patient is a 28-year-old male c/o of a red rash on his back. Pt
states this rash has “been there for weeks” but has noticed that the
rash is more visible after a hot shower. Pt denies any itching, pain,
tenderness or flaking of skin. Pt states “there are no symptoms except
seeing the splotches on my back.” Has tried OTC “antifungal creams
designed for athlete’s foot” with no relief. Pt denies prior history of
rash, contact with any individuals known to have a skin disorder, travel
out of the country, or contact between his bare skin and other surface
besides clothing. Pt denies any recent changes in soap, lotions,
shampoos, detergents, or fabrics. Pt states “I don’t think this rash is
contagious because my wife does not have it.” Pt denies open areas to
the skin. Pt denies any other instances of rash, lumps, sores, itching,
dryness, or color changes. Pt denies any changes to his hair or nails.
Patient denies any allergies.
PMH: Patient has a past medical history of chicken pox, and tonsillitis
and underwent a tonsillectomy in 2015.
FH: Patient’s father has a history of heart disease, high blood pressure,
and high cholesterol. Patient’s mother has a history of hypothyroidism
and gestational diabetes. Patient denies any family history of skin
cancers, skin disorders, or allergic skin reactions.
SH: Patient is a nonsmoker, nondrug user, and consumes 1-2 beers per
week. Patient participates in a regular exercise regimen 3-4 days per
week. Patient is married and is sexually active.
ROS:
General: Pt denies any recent weight changes, weakness,
fatigue or
fevers.
Head: Pt denies headache, head injury, or dizziness.
Eyes: Pt wears corrective lenses daily. Pt last eye exam was in
April 2015.
Pt denies any vision changes, pain, redness, excessive tearing,
double