History

CC:

Annual well visit and itchiness x1 week

HPI:

62 year old female presents today for a routine physical exam. Pt states that she has itchiness all over her body x1 week. When asked if the itchiness is localized to a specific region, pt denies and says it is diffuse and encompasses her whole body. She does mention that she noticed some “marks” on her L forearm and that there is particular itchiness behind her L knee at this moment. The itchiness is present throughout the day, with no worsening at any part of the day, and she has no relief. She did not apply any creams as she did not know what would be helpful. Pt is a home health aid and mentions that her client, who lives in a healthcare facility, has similar itchiness. When she asked her employers what her client had they said they cannot tell her and if she is having symptoms she should see her doctor. Pt says she did not recently travel out of the country or spend significant time outdoors. Pt also says that when she uses cleaning products she wears gloves. She does mention that when she gets home from work she does not immediately change clothes.

Denies any visible rashes, history of allergies, dry skin, change in medication regimen, weight loss, fever, and new soaps, detergents, foods. 

PMHx:

• Type 2 diabetes x unknown time
• HTN x unknown time
• Vitamin D deficiency x unknown time
• UTD on all vaccines

Medications:

• Insulin Lispro 100 U/mL 8-10 units before meals
• Basaglar 100 U/mL 20 units at bedtime for diabetes
• Glipizide 10 mg extended release BID for diabetes
• Empagliflozin 25 mg QD for diabetes
• Atenolol 50 mg QD for HTN
• Lisinopril 40 mg QD for HTN
• Vitamin D3 50,000 units for vitamin D deficiency 
• Denies herbal supplement use.

Past surgical history:

• Hysterectomy unknown year

Allergies:

• No known drug/food/environmental allergies

Family history:

• Mother: arthritis, DM, dementia- deceased
• Father: Unknown
• 2 children- alive and well

Social history:

• Smoking: Denies
• Alcohol: Socially
• Illicit drug use: Denies past or current use
• Marital History: Widowed
• Language: English
• Occupational History: Home health aid
• Travel: No recent travel
• Home situation: Lives at home with family
• Sleep: Endorses adequate sleep
• Exercise: Walks outside when the weather is nice
• Diet: Reports balanced diet with lean protein and vegetables. Carbs minimally.
• Caffeine: Denies caffeine use

Review of Systems:

• General– Denies fever, fatigue, chills, night sweats, weight loss/gain, changes in appetite.
• Skin, hair, nails– Admits to pruritus and circular mark on L forearm. Denies discolorations, moles, rashes, changes in hair distribution or texture.
• HEENT– Denies head trauma, vertigo, visual disturbances, ear pain, hearing loss, tinnitus, discharge, bleeding gums, epistaxis, nasal congestion and sore throat..
• Neck– Denies localized swelling/lumps, stiffness/decreased ROM
• Breast– Denies lumps, nipple discharge, or pain.
• Pulmonary– Denies dyspnea, wheezing, cyanosis, cough and hemoptysis.
• Cardiovascular– Denies chest pain, edema/swelling of ankles or feet, palpitations.
• Gastrointestinal– Denies abdominal pain, nausea, vomiting, jaundice, diarrhea, constipation, dysphagia, pyrosis, flatulence, eructation, rectal bleeding, hemorrhoids or blood in stool.
• Genitourinary– Denies urinary frequency, nocturia, urgency, flank pain, oliguria, polyuria and incontinence, vaginal discharge, dysuria and malodorous urine.
• Menstrual/Obstetrical– G2P2002, LMP age 50; not currently sexually active 
• Musculoskeletal– Denies back pain, muscle pain, joint pain, arthritis and joint swelling.
• 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, coldness or trophic changes, varicose veins, peripheral edema, or color changes.
• Hematologic– Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE.
• Endocrine– Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating, or hirsutism.
• Psychiatric– Denies feelings of helplessness, hopelessness, lack of interest in usual activities, or suicidal ideations, anxiety, obsessive/compulsive disorder, or ever seeing a mental health professional.

Physical

General:

• Well developed, obese female in no apparent discomfort. Appears stated age of 62. Neatly groomed, alert and oriented x3.

Vitals:

• BP: 124/56 mm Hg
• R: 16/min, regular rate and rhythm, unlabored
• P: 54 beats per minute, regular rate, rhythm and amplitude 
• T: 97.2 degrees F (temporal)
• Height: 66 inches Weight: 188 lbs BMI: 30.34

Skin/Head:

• Skin: Warm and moist, good turgor. Nonicteric. No scars or tattoos noted. Multiple small (1 mm) skin color circular lesions on L forearm in a cluster. Lesions are slightly raised with central punctum noted. One small lesion L popliteal area with central darker dot.
• Hair: No balding with average texture. No alopecia, seborrhea, or lice on exam.
• Nails: No clubbing, cyanosis, or lesions. Capillary refill < 2 seconds in upper and lower extremities.
• Head: Normocephalic, atraumatic with no evidence of contusions, ecchymoses, hematomas, or lacerations, and nontender to palpation throughout.
• Eyes: Symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink.
• Ears: Symmetrical and appropriate in size. No lesions, masses, or trauma on external ears. No discharge/foreign bodies in external auditory canals AU. TMs pearly gray/intact with light reflex in good position AU.

Nose/Sinuses:

• Nose: Symmetrical. No masses, lesions, deformities, trauma. No discharge visualized. Nares patent bilaterally. Nasal mucosa is pink and well hydrated. Septum midline without lesions, deformities, injection, or perforation. No foreign bodies.
• Sinuses: Nontender to palpation and percussion over bilateral frontal, ethmoid, and maxillary sinuses. 

Mouth/Pharynx:

• Teeth: Good dentition. No obvious dental caries noted.
• Tongue: Pink and well papillated. No masses, lesions or deviation. Mild fasciculation on exam. 
• Oropharynx: Well hydrated. No injection, exudate, masses, lesions or foreign bodies. Tonsils present with no injection or exudate. Grade 1 tonsils. Uvula midline, pink with no edema or lesions.

Neck/Trachea/Thyroid:

• Neck: Trachea midline. No masses, lesions, scars, pulsations. Supple and non-tender to palpation. FROM, no stridor noted. 2+ carotid pulses, no bruits or thrills noted bilaterally. No cervical adenopathy.
• Thyroid: Non-tender to palpation. No masses, thyromegaly, or bruits noted.  

Thorax/Lungs:

• Chest: Symmetrical, no deformities, no trauma. Respirations unlabored/ no paradoxical respirations or use of accessory muscles noted. Non-tender to palpation throughout. 
• Lungs: Clear to auscultation and percussion bilaterally. No adventitious sounds.

Cardiac:

• Heart: Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. 

Abdominal:

• Abdomen flat and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all 4 quadrants with no aortic/renal/iliac or femoral bruits. Nontender to palpation and tympanic throughout, no guarding or rebound noted. No hepatosplenomegaly to palpation. No CVA tenderness noted.

Pelvic:

• Genitalia: external genitalia without erythema or lesions. Vaginal mucosa Pink without inflammation, erythema or discharge. Cervix multiparous, pink and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. No inguinal adenopathy.

Neurologic:

• Cranial Nerves: CN I- XII are intact
• Mental status exam: Patient is well appearing, has good hygiene and is neatly groomed. Patient is alert and oriented to name, date, time and location. Speech and language ability intact, with normal quantity, fluency, and articulation. Patient denies changes to mood. Conversation progresses logically. Insight, judgment, cognition, memory and attention intact.
• Reflexes: Biceps, brachioradialis, triceps, patellar, and Achilles are 2/4 bilaterally. No clonus. Plantar reflex is downward bilaterally.
• Sensation: Sensation is intact bilaterally to pain and light touch. Two-point discrimination is intact. 
• Motor: Good muscle tone. Strength is 5/5 bilaterally at the deltoid, biceps, triceps, quadriceps, and hamstrings. 
• Cerebellar: Finger-to-nose and heel-to-shin test normal bilaterally. Balances with eyes closed (Romberg). Rapid alternating movements are normal. Gait is steady with a normal base. Coordination is intact as measured by heel walk and toe walk.

Peripheral vascular system:

• Extremities are warm and without edema. No varicosities or stasis changes. Calves are supple and nontender. No femoral or abdominal bruits. Brachial, radial, ulnar, femoral, popliteal, dorsalis pedis and posterior tibial pulses are 2+ and symmetric.

Musculoskeletal:

• No erythema, warmth or crepitus noted. Non-tender to palpation. Full range of motion of all upper and lower extremities bilaterally. 

Differential diagnosis:

• Bedbug bites
  • Bedbug bites typically appear to be small round lesions on a person’s skin. They range from being red to a lighter pink which often have a central punctum or darker dot. They are often in a cluster or linear pattern due to the fact that the bedbug made multiple bites in the same region. This is exactly what was seen on this pt. The pt’s primary symptom was pruritus, which is the main symptom of bedbug bites. Additionally, the fact that this pts client had itchiness makes this more likely due to its contagious nature.
• Scabies
  • Scabies causes severe itchiness and is very contagious. The history of this pt’s client also being itchy made me think of this diagnosis. However, the lesions on this pt’s body are not consistent with how scabies looks. Scabies generally look like burrows under the skin in the webbed spaces of the body. Also, the itchiness from scabies is usually worse at night which this pt is not experiencing. 
• Contact dermatitis
  • One of the main symptoms of contact dermatitis is itchiness. Additionally, being that the pt is a home health aid she deals with a lot of cleaning supplies and possibly could have had a reaction to one of those. However, she says she always uses gloves and did not start using any new products. She also has diffuse itchiness, whereas contact dermatitis causes more localized itchiness. Also, depending on whether it is allergic or irritant dermatitis will look slightly different. But generally, the area of skin that is irritated will look red, raised and very irritated. This was not present on the pt’s skin.
• Medication side effect
  • Itching is a listed adverse effect for both lisinopril and empagliflozin. However, it is a rare side effect for both of those medications. Additionally, being that there were visualized lesions on the skin, this is not a likely diagnosis.

Assessment:

• 62 year old female with PMHx of HTN, vitamin D deficiency and type 2 diabetes presents with complaints of skin pruritus x7 days. Pt also notices circular lesions on her L forearm. On exam, pt has a cluster of small, circular, raised lesions with central punctums on L forearm. One small lesion L popliteal area with central darker dot. All other parts of the exam are within normal limits. There are no labs or imaging available at this point. This is most consistent with a diagnosis of bedbug bites.

Diagnosis:

• Bedbug bites

Plan:

• Bedbug bites
  • Triamcinolone acetonide 0.1% to affected areas QD or BID
  • Claritin as needed
  • Pt education:
    • Diagnosis must be confirmed by pest control visualizing bedbugs in the home
    • If confirmed pest control should be contacted for pesticide placement
    • Clean the affected area thoroughly 
    • Wash clothes and dry them on the hottest setting the fabric can withstand 
    • Medications above may help the symptoms but will not eradicate the cause, these other steps must also be done to prevent recurrence
• Diabetes
  • Continue medications as prescribed
• HTN
  • Continue medications as prescribed
• Vitamin D deficiency
  • Continue medications as prescribed
  • Recheck vitamin D levels 3 months after most recently