CHIEF COMPLAINT: Foot pain, finger lesion, lip lesion.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who is here with a couple of complaints. One is a lesion on her foot. It has dried, cracked skin that has not resolved with any antibiotics she has taken. It has been going on for over a month. It is not associated with fevers or chills. She is not sure what precipitated this. The second is a pain in her finger. It has been going on for about a month as well. It has a redness. It is painful, dull, 2/10 pain, worse with movement. It is not relieved with anything she does, including antibiotics. The third is some lesions that are popping up on the inside of her lip. They have been going on for a week. They are not painful. Nothing seems to have made them better or worse.
PAST MEDICAL HISTORY:
1. Chronic back pain.
2. Methadone patient.
ALLERGIES: MULTIPLE DRUG ALLERGIES. SEE NURSE’S NOTE.
CURRENT MEDICATIONS: See nurse’s note.
SOCIAL HISTORY: Positive tobacco. No alcohol. Positive for methadone history.
REVIEW OF SYSTEMS: CARDIOVASCULAR: No chest pain. PULMONARY: No shortness of breath. GI: No abdominal pain. NEUROLOGIC: Chronic back pain. All other systems per HPI and otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 136/90, pulse 96, respiratory rate 16, and temperature 99.2.
GENERAL: The patient appeared well.
HEENT: Head: No signs of trauma. Pupils are 4-2. Extraocular movements are intact. Oropharynx: The patient on her lip had five small vesicle-type lesions but no crusting or pus. Oropharynx was otherwise clear. TMs were clear.
NECK: No adenopathy.
LUNGS: Clear to auscultation bilaterally.
HEART: S1, S2, regular rate and rhythm.
ABDOMEN: Soft, nontender, positive bowel sounds.
NEUROLOGIC: Cranial nerves intact. Motor is intact.
SKIN: The patient had a lesion on her distal fourth hand that was mildly red but no pus, tenderness or warmth. The foot had an area of crusting and dried skin with some cracking. There was no erythema, warmth or redness.
MEDICAL DECISION MAKING: The patient is a (XX)-year-old female here with three nonspecific complaints. There are no signs of an overwhelming infection or something that urgently needs to be treated. There are no signs of herpetic whitlow or herpes zoster in her mouth despite these nonspecific vesicular-type lesions. They did not, to me, appear to be herpes zoster. The patient at this time will be discharged to home. She will follow up with the primary care doctor for further treatment.
CLINICAL IMPRESSION: Lesions.
DISPOSITION: The patient was discharged to home.
PLAN: Follow up with the primary care doctor.
