Case: Krista Hampton
Instructions: Type patient encounter information directly into each box of the template similarly to your case studies.
CC: 25 y/o
... [Show More] F
“I have this ugly looking rash on my upper thighs”
HPI: Ms. Hampton is a 25 y/o female presenting with an itchy and tender
rash bilaterally on her inner thighs, and her left inner forearm. The rash
started about 36 hours ago after hiking in Napa with her boyfriend. She states
she spent time hiking, tried a new sunscreen, tried new foods such as scallops
and a new drink, as well as spending time in the hot tub with her boyfriend.
She reports that her boyfriend does not have similar symptoms, and that she
has not tried any treatments for the rash.
PMHx:
Child: “usual coughs and tummy ache nothing
remarkable.”
Adult Illness: Denies
SurgHx
Medical: None
Surgical: None
Obstetric: None
Hospitalizations: None
FamHx
Maternal grandfather died of CVD at age 81.
Grandmother (age 88) has prior heart attack, stent
and HTN.
Mother alive and well.
Father alive and well, treated for HTN.
Brothers - 35 and 32 both alive and well.
Sister - 21 alive and well.
SHx
Tobacco: Denies
ETOH: Socially
Illicit Drugs: Denies
Occupation: English teacher for 7
th and 8
th grade
Case: Krista Hampton
Relationship: Sexually active heterosexual female in a monogamous
relationship
Diet: Normal American Diet
Reproductive Hx
Age of menarche: “doesn’t remember.”
Menstruation cycle duration: “seems fine to me,”
regular periods
Sexual hx and concerns: Denies concerns
LMP: unknown
Breast screening: Conducts self-breast exams
Last Pap Smear: 1 year ago, with no signs of
abnormalities
Gravida para status/Childbirth hx:
Nulliparous
Allergies
Ceclor (Cefaclor) second generation cephalosporin – Patient developed hives
as child when taking this antibiotic for otitis media
List of Current Medications/supplements: Birth control pill
Supplements: None
Review of Systems: (ROS) Use this column to
document the ROS below.
General: Denies unintentional weight loss or gain,
chills, fever, and night sweats
Eyes: Denies any vision changes, discharge,
discomfort, dryness, or itching
ENT: Denies any swelling, redness, rhinorrhea, or
pain
Pulmonary: Denies SOB at night or at rest or when
lying down, denies cough, wheezing or difficulty
catching breath
CV: Denies palpitations denies heavy feeling or
From the ROS: list/highlight the current symptoms/complaints to
generate a list of pertinent “reported or denied” symptoms below:
Case: Krista Hampton
sensation of a “pounding heart
GI: Denies NVD, constipation, or heartburn. States
normal bowel movements
GU: Denies pain, burning, blood in urine, denies
difficulty starting or stopping urinating, dribbling,
incontinence, urgency during night or day, or any
changes in the frequency of urination
MS: Denies muscle weakness, joint pain, stiffness,
or swelling
Heme: Denies bruising, bleeding gums, nose
bleeds, abnormal bleeding, or history of anemia
Endocrine: Denies heat and cold intolerance,
increased thirst, increased sweating, frequent
urination, or changes in appetite
Derm: Patient states” Ugly looking rash on my
upper thighs, now it’s on my left inner forearm
too”, rash is “itchy and getting more tender”
Neuro: Denies dizziness, lightheadedness, fainting,
room spinning, seizures, or weakness
Psych: Denies anxiety, depression, loss of energy
or changes in interests
Derm: Patient states” Ugly looking rash on my upper thighs, now it’s on my
left inner forearm too”, rash is “itchy and getting more tender”
Physical Exam: (PE) Use this column to
document the PE below.
Vitals: Height: 5' 5" (165.0 cm)
Weight: 120 lb (55.0 kg) (BMI 20.0)
Temperature: 98.6 F (oral)
Pulse: 76 bpm - regular
Blood pressure: 116/62 mmHg - supine/sitting
From the PE: list/highlight the presence or absence of objective findings
to generate a list of pertinent “(+) or (-)” symptoms below:
Case: Krista Hampton
Blood pressure: 106/60 mmHg - upon standing
Respiratory rate: 12 bpm
SpO2: 94% on room air
General: Thin, pleasant, cooperative female, alert
and oriented x4
Skin: Skin on head, neck, back, chest, abdomen,
right arm: warm, dry, intact, no redness, itching or
swelling. Left inner forearm is noted with itchy
erythematous papules in linear configuration
with vesicles. Bilateral inner thighs noted with
raised confluent erythematous papules with
vesicles in various stages
Eyes: Lashes without crusting, eyelids without
edema, erythema. Conjunctivae pink, no discharge.
No orbital edema, redness, tenderness
ENT: Deferred
Neck: Deferred
Pulm: Respirations even and unlabored bilaterally,
good chest wall expansion, lung sounds clear to
auscultation bilaterally both anterior and posterior
CV: Heart rate and rhythm normal, no significant
change while standing, squatting and during
Valsalva maneuver, no JVD. 2+ peripheral pulses
x4 extremities, PMI in the 5th intercostal (ICS) at
the midclavicular line (MCL)
GI: Lean, non-distended, no scars noted, bowel
sounds audible in all 4 quadrants, no
hepatosplenomegaly, mass or herniation
Skin: Skin on head, neck, back, chest, abdomen, right arm: warm, dry, intact,
no redness, itching or swelling. Left inner forearm is noted with itchy
erythemat [Show Less]