History of present illness:
Onset: The rash began approximately 2 days ago.
Location: Initially present on bilateral inner thighs; now additionally observed on the left inner arm.
Duration: Continuous since onset.
Character: Itchy and feels tender.
Aggravating factors: Possible exposure during bushwhacking; contact with new lotion, hot tub, new
food (Scallops) may have contributed.
Relieving factors: None
Timing: Rash and itching are ongoing since onset, without remission.
Severity: Unable to rate severity of itching and rash impact.
Past medical history:
Illnesses/injuries: None
Obstetric: None
Hospitalizations: None
Surgeries: None
Preventative health:
Annual physicals
Dental checkups every 6 months
Annual Pap smears, last test negative for dysplasia or other changes
, All childhood immunizations up to date
HPV13 – Received
Received annual influenza vaccine, completed COVID-19 vaccines
Medications:
Oral contraceptive pill (OCP) – one pill per day, cannot recall name or dose.
Allergies:
Ceclor (Cefaclor): Reports hives as a child.
Social history
Tobacco: Denies
Alcohol: 2-3 5 oz glasses of wine on weekends, CAGE 0/4
Drugs: Denies
Diet: Typical North American diet
Activity: Runs 3 times per week. Bikes to work daily. Loves to go dancing.
Stressors: Denies any life major stressors
Living situation: Lives alone, stable housing
Support system: Support from family and boyfriend
Occupation: Education degree, looking for a teaching job
Safety: Wears a helmet when biking
Sexual history: Sexually active with one male partner; uses oral contraceptive pills
Family history:
Mother (58): Alive and well
Father (59): Has hypertension
Sister (21): Alive and well
Brothers (35 & 32): Both alive and well
Maternal grandfather: Passed away at 81, had a history of cardiovascular disease
Maternal grandmother: Passed away at 88, had hypertension and a history of myocardial infarction
(MI) with stent placement
Review of systems
General: Denies fever, chills, fatigue, night sweats, or weight loss. Overall health is good and n recent
illnesses.
Head: Denies headache, head trauma or injuries.
Eyes: No eye redness, pain, discharge, visual changes or itching around the eyes
Onset: The rash began approximately 2 days ago.
Location: Initially present on bilateral inner thighs; now additionally observed on the left inner arm.
Duration: Continuous since onset.
Character: Itchy and feels tender.
Aggravating factors: Possible exposure during bushwhacking; contact with new lotion, hot tub, new
food (Scallops) may have contributed.
Relieving factors: None
Timing: Rash and itching are ongoing since onset, without remission.
Severity: Unable to rate severity of itching and rash impact.
Past medical history:
Illnesses/injuries: None
Obstetric: None
Hospitalizations: None
Surgeries: None
Preventative health:
Annual physicals
Dental checkups every 6 months
Annual Pap smears, last test negative for dysplasia or other changes
, All childhood immunizations up to date
HPV13 – Received
Received annual influenza vaccine, completed COVID-19 vaccines
Medications:
Oral contraceptive pill (OCP) – one pill per day, cannot recall name or dose.
Allergies:
Ceclor (Cefaclor): Reports hives as a child.
Social history
Tobacco: Denies
Alcohol: 2-3 5 oz glasses of wine on weekends, CAGE 0/4
Drugs: Denies
Diet: Typical North American diet
Activity: Runs 3 times per week. Bikes to work daily. Loves to go dancing.
Stressors: Denies any life major stressors
Living situation: Lives alone, stable housing
Support system: Support from family and boyfriend
Occupation: Education degree, looking for a teaching job
Safety: Wears a helmet when biking
Sexual history: Sexually active with one male partner; uses oral contraceptive pills
Family history:
Mother (58): Alive and well
Father (59): Has hypertension
Sister (21): Alive and well
Brothers (35 & 32): Both alive and well
Maternal grandfather: Passed away at 81, had a history of cardiovascular disease
Maternal grandmother: Passed away at 88, had hypertension and a history of myocardial infarction
(MI) with stent placement
Review of systems
General: Denies fever, chills, fatigue, night sweats, or weight loss. Overall health is good and n recent
illnesses.
Head: Denies headache, head trauma or injuries.
Eyes: No eye redness, pain, discharge, visual changes or itching around the eyes
