Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
Chief Complaint: [Patient’s main concern, e.g., “Rash on legs”]
History of Present Illness:
Onset and duration of the rash.
Location and distribution of the lesions (e.g., legs, arms, face).
Characteristics of the lesions (e.g., size, color, crusting, drainage).
Any associated symptoms (e.g., itching, burning, pain).
Recent contact with anyone else with a similar rash.
Recent antibiotic use.
Past Medical History:
Briefly document any relevant past medical conditions, surgeries, or allergies, especially atopic dermatitis or weakened immune system.
Social History:
Ask about hygiene practices (frequent handwashing, showering).
Inquire about crowded living conditions or recent travel.
Medications:
List all current medications, including any topical creams or ointments applied to the rash.
Allergies:
Document any known allergies, especially allergies to antibiotics.
Family History:
Inquire about a family history of skin infections or atopic dermatitis.
Physical Exam:
Vital Signs: Include temperature (if concerning for systemic infection).
Skin Exam:
Describe the location, distribution, and characteristics of the lesions (e.g., multiple erythematous (red) papules or pustules with honey-colored crusts on the legs).
Differentiate between:
Ecthyma: Deeper, punched-out ulcers with surrounding inflammation, typically on the legs or buttocks.
Impetigo: Superficial, honey-colored crusted lesions, more common on the face, arms, and legs.
Assess for regional lymphadenopathy (swollen lymph nodes).
Assessment:
Ecthyma: Consider in cases with deeper, punched-out ulcerative lesions, especially on the legs or buttocks.
Impetigo: More likely if lesions are superficial and honey-crusted, particularly on the face, arms, or legs.
Consider differential diagnoses for skin lesions (e.g., folliculitis, herpes simplex).
Plan:
Topical Antibiotics:
Apply a topical antibiotic ointment (e.g., mupirocin) to the affected areas 2-3 times daily for 7-10 days.
Instruct on proper hygiene practices, including washing hands frequently and avoiding scratching the lesions.
Oral Antibiotics:
Consider adding oral antibiotics (e.g., cephalexin, amoxicillin-clavulanate) for more widespread or severe cases, especially ecthyma, or if topical therapy is ineffective.
Instruct on the importance of completing the entire course of antibiotics.
Hygiene Measures:
Emphasize the importance of good hygiene to prevent further spread of infection.
Recommend frequent handwashing and keeping the affected area clean.
Advise on avoiding scratching or picking at the lesions.
Follow-up:
Schedule a follow-up visit in 7-10 days to assess response to treatment.
Advise the patient to return sooner if there is worsening of symptoms, fever, or spread of the rash.
Discuss the importance of completing the entire course of antibiotics, even if symptoms improve.
Address any underlying conditions that may contribute to recurrent skin infections.
Note: This is a template and should be adapted to the specific patient encounter. Document all relevant details regarding the characteristics of the rash, associated symptoms, risk factors, physical exam findings, and treatment plan. Distinguishing features of ecthyma and impetigo should be noted in the assessment.