H&P #3

Identifying data:

  • Date & Time: February 21, 2023 9:00 am
  • Full name: R. R.
  • Address: ——-
  • Date of birth: –/–/–
  • Location: Jamaica, NY
  • Source of information: Self
  • Reliability: Reliable
  • Source of referral: Self

 

Chief Complaint: “Itchy scalp” x 1 month

 

History of Present Illness:

R.R. is a 45-year-old female with no significant PMHx complaining of dry, itchy scalp x 1 month. Patient states she has had increased amounts of stress in her life recently. States she notices white flakes falling from her head whenever she scratches. Reports her hair has been feeling greasier then normal. After symptom onset patient states she started a new shampoo (unknown name) for scalp dryness and symptoms worsened. Patient states she washes her hair 2 times per week and does not apply excessive products to hair. Denies pain, crusting, pustules, hair thinning.

 

Past Medical History:

  • No past medical history

Past Surgical History:

  • No past surgical history

Medications:

  • No medications
  • No herbal supplement use

Allergies:

  • No known drug allergies
  • No known food allergies
  • No known environmental allergies

Family History:

  • Mother: Age 71, alive and well, PMHx DM 2, HTN, HLD
  • Father: Age 73, alive and well, PMHx stroke at age 64
  • Maternal grandmother: unknown
  • Paternal grandmother: HTN, DM 2
  • Paternal grandfather: HTN
  • Maternal aunt: breast cancer age 62

Social History:

  • Smoking: non-smoker
  • Substance use: Denies alcohol use. Denies drug use
  • Caffeine: Denies caffeine use
  • Occupational history: Roti shop
  • Home situation: lives in apartment with husband

Review of Systems:

  • General: Denies generalized weakness/fatigue, fever, chills, night sweats, weight loss or gain, changes in appetite.
  • Skin, hair, nails: Admits to dryness of scalp, scalp pruritis, changes in hair texture. Denies discolorations, pigmentations, moles/rashes, changes in hair distribution.
  • Head: Denies head trauma, vertigo, headache.
  • Eyes: Denies contacts/glasses use, visual disturbances, eyelid swelling, pruritus, photophobia, lacrimation.
  • Ears: Denies ear pain, deafness, discharge, tinnitus.
  • Nose: Denies epistaxis, discharge, congestion
  • Mouth/throat: Denies sore throat, voice changes, bleeding gums.
  • Neck: Denies localized swelling/lumps, stiffness/decreased ROM
  • Breast: Denies lumps, nipple discharge, pain.
  • Pulmonary: Denies cough, dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, wheezing, cyanosis, hemoptysis.
  • Cardiovascular: Denies chest pain, edema/swelling of ankles or feet, hx of HTN, palpitations, irregular heartbeat, syncope, known heart murmur.
  • Gastrointestinal: Denies change in appetite, intolerance to specific foods, abdominal pain nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructations, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.
  • Genitourinary: Denies urinary frequency, urinary urgency, nocturia, oliguria, polyuria, dysuria, incontinence, flank pain, hematuria, history of hernias.
  • Menstrual/Obstetrical: G2, P(T2 P0 A0 L2), menarche age 14, LMP 1/31/23, regular menstrual cycles every 30 days. Denies hot flashes, vaginal discharge. Last pap smear exam 1 year ago, normal.
  • Sexual History: Admits to currently being sexually active with husband. Denies condom use. Denies history of STIs.
  • Musculoskeletal: Denies arthritis, muscle pain, deformity or swelling, redness.
  • Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
  • Peripheral vascular: Denies intermittent claudication, varicose veins, coldness or trophic changes, color changes, peripheral edema.
  • Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, history of DVT/PE.
  • Endocrine: Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating, goiter, hirsutism.
  • Psychiatric: Denies depression/sadness, anxiety, OCD, or ever seeing a mental health professional.

 

Physical Exam:

Vitals:

  • BP: 141/87 (seated, left arm)
  • HR: 91 BPM (regular)
  • RR: 16/min (unlabored)
  • T: 97.1 F (oral)
  • O2: 97% (room air)
  • Height: 64in Weight: 173bs     BMI: 29.7

General: AAO x 3, appears in no acute distress, well groomed, appears stated age

Skin: Warm & moist; good turgor; non-icteric; no rashes or lesions noted

Head: Normocephalic, atraumatic, non-tender to palpation throughout

Hair: Normal hair distribution. Greasy texture with fine white scaling. Erythematous plaques noted at frontal hairline.

Eyes: PERRLA. Visual fields full OU. EOM intact, no nystagmus. Sclera white, cornea clear, conjunctiva pink.

Ears: TM pearly grey and intact with light reflect in good position AU. No tenderness, discharge or foreign bodies.

Nose: Symmetrical. Nares patent bilaterally, nasal mucosa pink.

Sinus: Non-tender to palpation.

Mouth/pharynx: Mucosa pink and well hydrated. Pharynx non-erythematous. No exudates or lesions visualized. Uvula midline.

Neck: Trachea midline. Supple and non-tender to palpation. No cervical lymphadenopathy noted.

Cardiac: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmur.

Chest: Symmetrical, no deformities. Respirations unlabored, no accessory muscle use.

Lungs: Clear to auscultation bilaterally.

Abdomen: Abdomen flat and symmetric, no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants. Tympanic throughout, nontender, no guarding or rebound noted. Negative CVA tenderness.

Nervous system: Cranial nerves I-XII intact.

Peripheral vascular: Pulses 2+ bilaterally in upper and lower extremities. No clubbing, cyanosis or edema noted.

Musculoskeletal: FROM (full range of motion) of all upper and lower extremities bilaterally. Non tender to palpation.

Female genitalia: exam not performed.

Rectal: exam not performed.

 

Differential Diagnosis:

  1. Seborrheic dermatitis
  2. Contact dermatitis
  3. Psoriasis
  4. Tinea capitis

 

Assessment:

R. R. is a 45yo female complaining of dry, itchy scalp x 1 month. On exam, there are erythematous plaques noted at the frontal hairline. Greasy texture with diffuse white scaling is noted. Hair distribution is normal. Signs and symptoms are consistent with seborrheic dermatitis.

 

Diagnosis: Seborrheic Dermatitis

 

Plan:

  • Ketoconazole cream 2%: apply to affected area twice daily for 4 weeks
  • Switch to anti-dandruff shampoo (selenium), continue to wash twice a week
    1. If hair continues to be greasy, consider washing 3 times per week
  • Prevention:
    1. Limit styling products placed in hair
    2. Limit stress
    3. Rinse hair thoroughly
    4. Eat a healthy diet – zinc, vitamin B can help prevent dandruff
  • If symptoms persist, follow up with dermatologist