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Skin rash: what would you do?

Chief Complaint

Jim C is a 31 year old male. The “Rash” screening questionnaire was administered.

History of Present Illness

#1. “Rash”

Duration

He reported: Skin rash 24 to 72 hours. Skin itching less than 24 hours.

Quality

He reported: Skin rash blanches. Rash red, separated, individual spots, and blistered. Rash arranged in a line. Rash grouped together. Raised itchy bumps or welts that are red at the edges. Crusted skin sores. Multiple small blisters less than 1/2 inch or 1 cm.

He denied: Skin rash single darkened area surrounded by redness. Rash small, single, pinpoint-like spots. Pus in skin. Areas that look like bruises or blood in the skin.

He reported: Health status good.

Location

He reported: Skin rash located on the left arm. Rash confined to one region of body.  Itching only in one place.

Context

He denied: Walking in the woods in the last week. Working outdoors in the last week.

Modifying Factors

He denied: Skin rash worse with sunlight.

Associated Signs and Symptoms

He reported: Change in skin colour. Rash skin a different colour.

He denied: Discharge from skin lesions. Itching disturbs sleep.

Past, Family, and Social History

He denied: Psoriasis. Loss of pigment of the skin. A significant loss of hair colour before the age of 30 years.

Social History

He denied: Military service. Travel 100 miles (150 km) outside the local area within 3 months of illness. Household or family members have similar rash.

Activities for Daily Living

He reported: Normal daily activities not at all difficult because of skin rash.

Environmental Hazards

History of: Using ordinary soap.

He denied: Using hair products. Change in skin care products recently.

Medication History

Ongoing Medications

He denied: Use of antibiotics within the last month.

Past Medications

He denied: Steroid cream prescribed.

Over-the-counter Medications

He denied: Topical moisturisers. He reported: No medication used on skin rash.

Review of Systems

Gastrointestinal

He denied: Yellowing of the skin.

Psychiatric

Anxiety Disorders

He denied: Felt nervous, anxious, or under stress.

[NOTE:  if using a smartphone, the patient can take a photo and attach here]

GPs, what would you do first?

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