Josh Rodrigues

DOB: 12/13/1966

CC: Body Rash

NKDA

S-Josh Rodrigues is 47 yrs old Hispanic American Male presents to the clinic
complaining of a rash on nose and facial flushing since last five days. He feels a burning
sensation around the rash area. Patient tried to self medicate the rash with corticosteroid
creams but reports that the burning or stinging is exacerbated when he applies the cream.
He denies any relieve and improvement of the rash with the topical agent. He complained
that his skin around his nose was extremely dry and he was experiencing some skin
thickening and his wife noticed that his facial flushing worsened when drinking his
morning coffee, after doing yard work, and especially after his nightly glass of wine. He
owns a construction business and spends most of his day out in the sun without any use
of sunblock. Patient denies fever, chills, or sick contacts. He is also concerned with
developing DM since it runs in the family.
PMH:
His medical hx is unremarkable. Denies history of asthma, GERD, dermatitis, diabetes,
heart disease, liver disease, kidney disease or cancer.
Childhood illnesses: childhood allergies (pt. unaware of specifics), recurrent ear
infections
Surgical Hx: Appendectomy at age 25
Psychiatric Hx: Denies
Social hx: Friendly patient in minimal distress but concerned about his symptoms.
Enjoys gardening and outdoor activities. Denies smoking and drug abuse. Takes a glass
of red wine every night before bed.
Family History: Mother - DM, HTN. Father- DM, HTN, CAD. No family history of
IBS, obesity, stroke, kidney disease, lung disease, liver disease, seizure disorder, or
mental illness.
Current medications: OTC: Advil prn. Cortisol 1% prn for the skin rash.
NKDA
Social hx: Friendly patient in minimal distress but concerned about his symptoms.
Enjoys gardening and outdoor activities. Denies smoking and drug abuse. Takes a glass
of red wine every night before bed.
ROS (Review of Systems)
CS (constitutional systems): as per HPI.
Eyes: Denies headache, visual changes, double vision, and eye pain, floaters or blind
spots (scotomas).
Neuro: WNL.
Ears, nose, mouth and throat (ENT): Denies sinus pain, pain with swallowing, sore throat.
Pt. denies stuffy or painful ears, toothache.
Cardiovascular: Pt. denies shortness of breath, loss of consciousness, oedema, chest pains
or palpitations.
Respiratory: Denies cough, haemoptysis, exercise intolerance, wheezing, and sputum.

Lungs are clear to auscultation.

Abd: Pt denies abdominal pain, constipation or diarrhea, N/V, or changes in stool pattern.
(O) OBJECTIVE
PE (Physical examination)
VS: P 85, B/P 127/82, HR 69, RR 18, height 65, Weight 162lb:
General: Alert & oriented x3, well nourished, well groomed, appropriate affect, in no
acute distress (NAD), responds appropriately to interview and questions.
HEENT (head, eyes, ears, neck and throat): Normal
Skin: Dry and warm, thickening of the skin, telangiectasia observes around the cheeks
and bridge of the nose.
Cardiovascular: Femoral pulses 2+, RRR having S1, S2, no murmurs, gallops or rubs.
Respiratory: Bilateral breath sounds (BBS) clear to auscultation
Abdomen: BS present x 4 quads, normoactive, soft, non-distended, non-tender.
Neuro: Cranial Nerves Intact and functioning well.
Neck: Supple, no lymphadenopathy, no bruits
Assessment:
Subtype 1 (erythematotelangiectatic rosacea), characterized by flushing and persistent
redness, and may also include visible blood vessels.
Check HgbA1c- High risk due to age, weight and family Hx.
Plan:
Finacea 15% gel tp daily in the morning and bedtime. Reassess if no improvement in 12
weeks.
Advice patient against alcohol, exposure to the wind, sun, or extremely cold weather,
exercise and stress. Also ask patient to use SPF of 30 or higher.
HgbA1c- 5.9
Advice patient pt that he must eat healthy and exercise to improve his chances of
avoiding DM. Give printed Instructions for DM. A follow up appointment is scheduled
in 3 months unless symptoms worsen or new ones develop.