Patient Name (uniquely assigned/not original pt. name): X. X. Date of Service: 9/16/21
Age: 28 years old DOB: XX/X/XX92 Race: Indian
Gender: Female Insurance: Graduate School/ University Provided. No referral
PCP: Dr. Jacob Jacobson, DNP-FNP
Chief Complaint:
“I am here because I developed small red, irritatingly itchy bumps that started on just my arms/legs/face
and spread everywhere. Starting 2 days prior after doing corn research for school in the fields.”
History of Present Illness (HPI): Patient as own historian
Patient presents to the clinic today with an itchy, papular rash primarily on trunk and upper extremities that
started last Wednesday-Thursday. Reports that the rash started after she took part in a field sampling
experience here at NDSU, in which they sampled corn from different fields for 2 hours Tuesday-Friday last
week. She waited until today to come in to see if the rash would get better on its own over the weekend and
until she knew was completely done doing field samples. Reports that the rash has not gotten better since her
last day in the fields Friday, if not got worse over the weekend. She has had no upper respiratory symptoms,
cough, fever, SOB, congestion, or other symptoms within the last two weeks and has had no other known
exposures. She does report having allergies in the spring to pollen and other spring allergens. She has not tried
any OTC medications or creams/topical medications to treat the rash or itching and thus far nothing makes it
better and showering or hot/humid environments/situations make the rash really red, itchier, and much worse.
Immunizations Status: All childhood & recommended immunizations + TDAP up to date.
Allergies
No known drug allergies
Unspecified environmental allergies, seasonal in the spring
No known latex, food, or other allergies
Current Medications
-Bupropion HCl 150 mg tablet extended release 24 hr PO once daily in A.M. (to treat depression/anxiety)
-Escitalopram oxalate/Lexapro 20 mg tablet PO once daily in A.M. (to treat depression/anxiety)
-Cholecalciferol/vitamin d3 1,000-unit tablet PO once daily (prevent vitamin D deficiency r/t increased risk)
-Daily Women’s Multivitamin w/ iron tablet PO once daily (nutrition/vitamin/mineral supplement)
Medical History/Chronic Conditions
Generalized Anxiety Disorder (Active-Controlled)
Recurrent Major Depressive Disorder, Moderate (Active-Controlled)
Environmental allergies w/ seasonal allergic rhinosinusitis (spring season) (Inactive at this time)
