Rash persisting for one year, exacerbated by itching.
History of Present Illness
Onset of symptoms: Approximately one year ago.
Symptom description: Persistent rash, predominantly on the medial thighs, with periodic exacerbation of pruritus.
Aggravating/Alleviating factors: Intermittent itching with variable severity. Previous treatment with ketoconazole cream resulted in limited improvement. Recent use of hydrocortisone cream has provided better symptomatic relief.
Previous management: Ketoconazole cream and hydrocortisone cream applied topically. Oral Clindamycin was discontinued due to potential allergic reaction manifesting as white spots on the skin. The patient reports no recent lab testing.
Additional context: Reports intermittent effectiveness of treatments.
Past Medical History
Significant conditions: Historical diagnosis of myocarditis. Unspecified childhood illness.
Medication History: Not currently detailed.
Personal History
Unremarkable. No recent anxiety or depression. Blood pressure reportedly within the normal range. No history of surgeries. Unknown status of smoking, alcohol consumption, diet, or exercise habits.
Family History
No known familial history of hypertension, diabetes, malignancies, or other significant diseases.
Physical Examination
Vital signs: Not documented in the transcript.
Examination findings: General physical examination unremarkable. Specific focused examination on skin rash locations, revealing pruritic lesions.
Auxiliary Examinations
Recommendations for comprehensive lab tests including CBC, CMP, lipid profile, blood glucose, and serological tests for hepatitis A, B, C. Immunization status suggests the need for tetanus, hepatitis B, and flu vaccines.
Diagnosis and Assessment
Preliminary Diagnosis: Chronic pruritic dermatitis with suspected fungal component.
Differential Diagnosis: Eczema, fungal infection, other forms of dermatitis.
Treatment Plan
Medications: Prescription of a more potent topical steroid for itch relief, continuation of ketoconazole for antifungal therapy.
Lifestyle Interventions: Not specifically mentioned.
Further Examinations: Comprehensive lab testing for serological profiles, including liver functions and hepatitis screenings. Immunizations for tetanus and flu.
Notes:
Follow-up scheduled in one week for test results and further management.
The patient is referred to a nearby laboratory for blood draws and vaccinations.
Depending on lab results, further specialist referral or treatment modifications may be necessitated.