CHIEF COMPLAINT: The patient thinks he has ringworm.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old boy whose mom states that she has noticed that he has been itching his foot a lot, so she took a look at the area. It is a round and circular area on his foot that has been itching a lot. He says that he is always barefoot, always playing in the woods, and playing everywhere. He states that he could have picked it up anywhere. No one else in the family has it. He denies any itching or any rashes to his mouth.
PAST MEDICAL HISTORY: None.
MEDICATIONS: None.
ALLERGIES: None.
SOCIAL HISTORY: He is here tonight with mom.
REVIEW OF SYSTEMS: As stated above in the HPI. All other systems reviewed are negative.
PHYSICAL EXAMINATION:
GENERAL: The patient is a well-developed, well-nourished boy, in no acute distress.
VITAL SIGNS: He is afebrile. Pulse oximetry is 99% on room air, interpreted as normal.
HEENT: Pupils are equal, round, and reactive to light. Extraocular movements are intact. Sclerae and conjunctivae are noninjected. Oropharynx is clear without any erythema or edema.
NECK: Supple. No lymphadenopathy. Full range of motion of his neck without any pain.
LUNGS: Clear to auscultation. No wheezes, rales, or rhonchi.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, and nondistended. Bowel sounds are normal.
EXTREMITIES: In his right lower extremity, he does have a well-demarcated circular area on the dorsum of the right foot. It does appear to be fungal in nature. He also has multiple abrasions on his legs and different bruises, but this area is certainly quite different. No significant erythema surrounding the area. No pustules noted. No vesicular lesions.
IMPRESSION: Ringworm.
PLAN: It appears the patient does have what is consistent with ringworm. We will start him on clotrimazole lotion or cream. We will ask mom to apply it twice a day and that she should have a followup with a pediatrician to make sure it is improving. However, she should not expect any improvement for at least a couple of weeks. She certainly should return for any problems or concerns.
