Report 3
Name: Rob Ritchie
#030204
Dr Anne Jones
1
HISTORY AND PHYSICAL EXAMINATION
HISTORY
CHIEF COMPLAINT
Patient developed a rash of the right calf with swelling and tenderness.
HISTORY OF PRESENT ILLNESS
The patient had joined a gym 1 month ago and noticed the onset of the rash 1 week prior to
admission beginning with redness and progressing to small blisters. He had a fever since
yesterday with chills and malaise.
PAST HISTORY
Noncontributory.
ALLERGIES: NO KNOWN ALLERGIES.
REVIEW OF SYSTEMS
Skin: There is itching between the 1st and 2nd digits of the right foot for approximately 1 month.
Other systems are noncontributory.
PHYSICAL EXAMINATION
GENERAL: This is a well-nourished, well-developed 22-year-old white male who is pleasant
and cooperative.
VITAL SIGNS: Pulse 100, regular. Blood pressure . Respiratory rate 20, regular.
Temperature 102 °F.
HEENT: Head: Normocephalic. Eyes: EOMs intact. Ears: The tympanic membrane is normal to
inspection.
NECK: Supple. No adenopathy.
CHEST: The heart and lungs are normal to percussion and auscultation.
ABDOMEN: There is right inguinal adenopathy. The abdomen is soft without evidence of
organomegaly.
RECTAL: The prostate is normal in size. No blood is seen on the examining finger. Stool guaiac
negative.
EXTREMITIES: There is a large, well-demarcated, shiny, red, edematous, tender rash covering
most of the lateral aspect of the right leg with peripheral tenderness. Vesicles are present. In
addition, there is an intertriginous rash between the 1st and 2nd digits of the right foot.
NEUROLOGIC: Except for tenderness in the right leg, no deficits are demonstrated. DTRs are
normoreflexive.
IMPRESSION
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3
1. Febrile vesicular rash, right leg, most likely erysipelas.
2. Intertriginous fungal infection, right foot, between the great toe and second.
PLAN
1. Blood cultures stat.
2. Penicillin G 1.2 million units IV q.6 h. for 36 hours.
3. If there is a rapid response, switch to Pen.Vee K 250 mg p.o. q.i.d. on an outpatient basis for
14 days.
4. Cold packs p.r.n. for pain.
5. Aspirin 600 mg p.o. q.3 h. p.r.n. for pain.
____________________________________
Anne Jones, MD
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AJ:
Footnotes
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Doctor mispronounces patient’s name. Always double check patient names and numbers with the patient list.
No commas before age or race. See Rule 20 exception.
Flag the doctor for the irregular BP dictated here.
Rule 6 exception- “second” is being used a noun here.
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Include a space following the number in dosage abbreviations like q.6 h. See Rule 6.
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Rule 69
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